WAR-SHOCK 


In  the  Press. 

STUDIES  IN  WORD -ASSOCIATION 

Edited  by  Dr.  C.  G.  JUNG.  Translated  by  Dr. 
M.  D.  EDER. 

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HYPNOTISM,      OR      SUGGESTION 
AND  PSYCHOTHERAPY 

By  Dr.  AUGUST  FOREL.  Translated  by  H.  W. 
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LONDON  :    WILLIAM    HEINEMANN 


WAR-SHOCK 


THE    PSYCHO-NEUROSES    IN    WAR 
PSYCHOLOGY     AND       TREATMENT 


By 

M.  D.  EDER, 

B.Sc.  LOND.,  M.R.C.S.,  L.R.C.P.  LOND. 

Late  Temporary  Captain  R.A.M.C.,  and  Medical  Officer  in 
charge  of  PsychorNeurological  Department,  Malta 


feriuntque  sumna* 
Fulgura  monies. 


LONDON 
WILLIAM    HEINEMANN 


London:  William  Hein<mann,  19  7 


PREFACE 

As  the  material  for  this  book  I  have  taken  the  first 
hundred  consecutive  cases  of  psycho-neurosis  which 
came  under  my  care  ;  the  psychoses  have  been  ex- 
cluded. A  certain  number  of  these  hundred  patients 
were  admitted  into  the  general  surgical  and  medical 
wards  of  which  I  had  charge  in  the  earlier  stages  of 
the  Gallipoli  campaign ;  the  larger  number  were 
patients  who  were  sent  into  the  special  department 
which  was  formed  later  on  and  entrusted  to  me.  By 
limiting  the  detailed  observations  to  a  small  number  of 
patients,  who,  however,  present  collectively  the  chief 
varieties  in  the  symptoms  and  psycho-pathology  of  war- 
shock,  a  better  basis  is  secured  for  the  understanding 
of  this  condition  than  could  be  obtained  by  a  more 
general  account  of  larger  numbers. 

No  claim  is  made  for  regarding  the  figures  given  in 
this  book  as  of  universal  validity.  In  medicine,  perhaps 
especially  in  psychological  medicine,  mere  statistics 
are,  I  believe,  of  little  value,  and  are  more  prone  to 
occasion  erroneous  deductions  than  the  detailed  records 
of  a  few  cases. 

The  appendix  (pp.  146-152)  gives  a  summary  of  the 
aetiology,  symptoms  and  results  of  treatment  of  these 
first  hundred  patients. 

Through  the  friendly  interest  in  the  work  taken  by 
my  commanding  officer,  Lt.-Col.  Scanlan,  R.A.M.C.,and 
the  ever  willing  co-operation  of  the  nursing  staff,  I  was 


Ti  PREFACE 

able  to  live  with  these  patients  for  hours  and  days 
together  ;  it  was  possible  to  make  a  fairly  intensive  study 
of  their  difficulties  and  troubles. 

To  many  of  my  one-time  colleagues  in  the  Malta 
Command  I  am  indebted  for  help  in  securing  the  well- 
being  of  the  patients  :  to  them  my  thanks.  More 
especially  to  Surgeon-General  Whitehead,  A.M.S.,  who 
sanctioned  the  creation  of  the  special  department,  and 
to  Col.  Purves  Stewart,  Consulting  Physician  to  the 
Malta  Command.  Col.  Stewart  saw  most  of  the  patients 
before  they  came  into  the  department ;  he  took  the 
liveliest  interest  in  their  progress,  and  was  ever 
generous  in  allowing  me  to  have  his  earlier  records  of 
the  cases.  My  friend,  Dr.  H.  Wingfield,  I  must  thank 
for  his  kindness  in  reading  through  the  proof  sheets. 

This  book  does  not  pretend  to  deal  exhaustively  with 
the  ultimate  concepts  of  the  psycho-neuroses.  I  have 
had  in  mind  two  considerations  :  to  give  so  much  of 
the  psychology  as  to  make  the  symptoms  intelligible, 
and  to  show  that  soldiers  suffering  from  war-shock 
respond  peculiarly  well  to  psycho-therapeutic  treatment. 
It  offends  the  scientifically  trained  mind  to  read,  as  I 
did  to-day  :  "  A  soldier,  who  became  dumb  two  years 
ago  after  an  explosion,  suddenly  recovered  his  speech  at 
a  cinematograph  show." 

It  is  not  necessary  that  a  soldier's  cure  should  have 
to  depend  upon  the  chance  stimulation  of  his  emotions 
at  some  greater  or  lesser  interval  after  his  injury. 
Medical  science  can  to-day  reduce  this  period  of  misery 
and  suffering  to  a  few  days  in  the  vast  majority  of 
soldiers  afflicted  by  shell-shock. 

The  book  was  planned  and  mostly  written  whilst  on 
service,  a  condition  which  prevented  any  attempt  at 
a  critical  study  of  the  literature.  This  cannot  be  made 
till  the  war  is  ended.  I  have  preferred  to  have  this  book 


PREFACE  vii 

published  during  the  war  in  the  hope  that  my  experi- 
ences may  be  useful  to  others,  may  assuage,  in  howso- 
ever small  a  degree,  the  sufferings*  of  that  most  splendid, 
cheery  and  heroic  figure,  the  British  soldier,  none  other 
than  the  common  Briton — the  working  man  whose  very 
same  virtues  we  too  often  fail  to  recognise  without  the 
khaki. 

M.  D.  EDER. 

*  Since  this  was  written  the  following  is  one  of  several  similar 
cases  that  have  come  under  my'notice : — A  clerk,  aged  26,  enlisted 
at  the  beginning  of  the  war.  After  several  months  in  the 
trenches  he  got  shell-shock ;  tried  to  carry  on  for  some  days, 
but  was  then  ordered  to  hospital.  He  remained  in  a  hospital 
and  a  camp  for  nearly  ten  months  without  any  improvement. 
He  was  then  discharged  from  the  Army  with  a  gratuity  of  £20. 
Believing  himself  now  given  up  by  the  doctors  as  incurable,  and 
thinking  that  he  would  never  support  himself,  he  grew  more 
despondent  than  ever.  When  some  weeks  later  he  came  under 
my  notice  he  was  suffering  from  exhaustion,  confusion  of  ideas. 
causeless  terrors,  want  of  concentration,  so  that  he  could  not 
read  or  write  a  few  lines  or  add  a  couple  of  figures.  He  was 
being  supported  by  his  friends  and  relatives.  A  few  weeks 
treatment  restored  him  to  the  normal  and  put  him  in  a  position 
to  earn  a  livelihood. 


CONTENTS 


CHAP.  PAGE 
PREFACE 

I.     INTRODUCTION     ...         ...         ...         ...  i 

II.     CONVERSION- HYSTERIA  ...         ...         ...  20 

III.     PSYCHOLOGICAL   MECHANISMS   IN   CON- 
VERSION HYSTERIA      -..         ...         ...  48 

IV.     ANXIETY- HYSTERIA         ...          ..         ...  78 

V.       PSYCHASTHENIA     ...             ...             95 

VI.     DIAGNOSIS           ...  118 

VII.    TREATMENT         128 

VIII.     SUMMARY  OF  CONCLUSIONS       144 

APPENDIX,     SUMMARY     OF     100    CON- 
SECUTIVE CASES           ...         ...         ...  146 

INDEX        153 


CHAPTER  I 
INTRODUCTION 

THE  institutes  of  medicine  remain  unshaken  by  the 
war.  It  has,  however,  raised  many  new  medical 
questions,  thrown  fresh  light  on  old  problems,  and 
demanded  the  application  of  the  ancient  principles 
under  novel  conditions. 

The  war  has  apparently  created  some  new  diseases  : 
we  read  of  trench-fever,  trench-nephritis,  and  so  on. 
In  the  sphere  of  the  psycho-neuroses  no  new  diseases 
are  to  be  discovered.  Oppenheim  has,  it  is  true, 
written  a  book  upon  them,1  but  his  new  diseases — 
reflex  paralysis,  akinesia  amnestica — seem  but  due 
to  his  ignorance  of  contemporary  psycho-pathological 
work.  His  German  critics,  Birnbaum,  Lewandowsky, 
and  others,  have  sufficiently  dealt  with  his  claims. 
(See  the  discussion  at  the  Berliner  Gesellschaft  fur 
Psychiatric,  in  the  Zeitschrift  fur  die  gesamte 
Neurologic  und Psychiatric.  (Bd.  12,  Heft.  4, 1916, 
p.  427.)) 

But  though  no  new  diseases  have  been  produced 
by  the  war,  we  have  learnt  much  that  is  new  about 
the  old  diseases,  and  obtained  new  evidence  confirm- 
ing earlier  views.  We  have  learnt  that  a  psycho- 
neurosis  can  be  produced  by  stress  of  external  condi- 
tions, acting  on  a  mind  which  is  but  a  degree  or  so 
more  sensitive  than  the  normal  person's — a  sensitive- 

1  ' '  Die  Neurosen  nach  Kriegsverletzungen. 

i 

B 


2  WAR-SHOCK 

ness  which  should  have  involved  no  disability  in 
normal  life,  rather  the  contrary — it  might  tend  to 
success  in  a  man's  particular  vocation,  or  make  an 
artisan  take  a  lead  in  the  affairs  of  his  own  trade,  or 
parish  affairs,  or  enter  Parliament.  This  psycho- 
neurosis  is  what  I  call  War-shock. 

It  is  to  these  conditions  'hat  Grasset2  refers  as 
presenting  "la  forme  classique  de  1'ancienne  hemi- 
plegie  hysterique." 

Though  the  form  is  the  same,  there  is  a  difference 
in  kind ;  in  war-shock  the  external  psychic  factor  is 
overwhelmingly  greater  than  the  second  factor — the 
predisposition. 

This  view  is  also  maintained  by  Benon,3  who 
writes :  "  L' importance  attachee  pratiquement  au jourd'- 
hui  a  la  predisposition  ou  mieux  aux  causes 
predisposantes  est  tout  a  fait  excessive." 

We  also  find  among  soldiers  suffering  from  the 
same  symptoms  cases  which  correspond  to  the  psycho- 
neuroses  more  commonly  seen  in  civil  life.  These  I 
call  here  non- war-shock  cases. 

The  aim  of  this  little  book  is  essentially  a  practical 
one ;  it  is  hoped  to  give  an  understanding  of  the 
mental  processes  at  work  in  these  affections,  so  as 
to  provide  the  sound  basis  for  their  adequate  treat- 
ment. Professor  Elliot  Smith  in  a  valuable  paper* 
writes:  "Everyone  who  has  had  any  dealings 
with  the  patients  in  the  military  hospitals  scattered 
throughout  this  country  must  admit  that  much  more 
might  be  done  for  patients  suffering  from  some  of  the 
protean  manifestations  of  shock  than  is  being  attempted 
at  present.  .  .  .  Such  patients  may  recover  of  them- 

2  "Les  psychonevroses  de  guerre":  Presse  Medicale,  191b, 
p.  105. 

3  "Les   maladies  mentales  et  nerveuses  et  la  guerre." — 
R.  Benon.    Revue  Neurologique,  Fevrier  1916.    No.  2,  p.  215. 

4  "Shock  and  the  Soldier."    The  Lancet,  April  15  and  22, 
1916,  p.  813. 


INTRODUCTION  3 

selves  without  any  attention,  but  a  large  number  of 
them  tend  to  get  worse,  and  if  they  are  left  without 
attention  their  symptoms  are  apt  to  become  stereo- 
typed into  definite  delusions  and  hallucinations." 

There  is  no  reason  why  this  should  be.  The 
symptoms  respond  to  treatment  quite  as  readily  as 
surgical  or  infectious  affections ;  nor,  in  the  majority 
of  cases,  need  the  active  treatment  be  very  pro- 
longed. 

My  earlier  nerve  cases  had  to  be  picked  out  from 
the  heterogeneous  diseases,  mostly  surgical,  admitted 
to  my  wards :  e.g.,  in  the  very  first  batch  of  patients 
admitted  to  my  wards  the  day  our  hospital  was 
opened,  June  10th,  1915,  was  a  hysterical  deaf-mute. 
I  am  thus  enabled  to  confirm  from  personal  experience 
the  statements  of  others  that  functional  diseases  are 
rare  among  the  wounded.  I  cannot  go  so  far  as 
Wiltshire,  who  claims  that  "Shell-shock  is  not  to  be 
seen  in  surgical  wards,"  i.e.  "as  exemplified  by 
monoplegias,  paraplegias,  mutism,  somnambulism, 
fits,  hysterical  fits,  and  neurasthenia"5:  out  of  150 
cases  only  14  had  been  wounded. 

Horstmann6  has  seen  no  functional  diseases 
among  the  wounded,  whilst  Nonne 7  says  they  are 
very  rare.  Rothmann8  and  Oppenheim,9  on  the 
other  hand,  say  that  functional  diseases  are  very 
frequently  associated  with  organic  lesions. 

The  following  table  shows  in  100  consecutive  cases 
(the  psychoses  have  been  excluded)  the  relationship 
between  surgical  injury,  shell-shock  and  functional 
disease. 

5  Harold    Wiltshire.      "A    Contribution    to   the   Etiology 
of  Shell-Shock."     Lancet,  June  17,  1916.  p.  1207. 

6  Quoted  Zeitschrift  fur   die   gesamte  Neurologic  u.    Psy- 
chiatric, April,  1915,  Bd.  11,  Hf.  5,  p.  344. 

7  Ibid,  p.  344. 

8  Ibid.  p.  345. 

9  "  Zur    Kriegsneurologie."      Berliner    klinische    Wochen- 
schrift,  1914.     No.  48. 


4  WAR-SHOCK 

Without  previous  injury,  shell-shock,  etc. . . .  53 

Following  shell-shock         19 

Associated  with  injury  such  as  wound,  fall, 

etc.  (frost-bite  in  two  cases)  ...         ...  28 

100 
\ 

Shell-shock  has  been  given  prominence  on  account 
of  its  prevalence  and  the  various  hysterical  symptoms 
that  have  followed  the  high  explosions.  Exactly  the 
same  symptoms  have  occurred,  however,  after  shrap- 
nel wounds,  falls,  and  without  previous  injury  at  all. 
We  take  note  of  shell-shock  in  the  aetiology,  but  to 
make  it  into  an  independent  disease  (apart  from 
practical  convenience)  is  about  as  valuable  as  it  would 
be  to  regard  enteric  fever  arising  from  drinking 
polluted  water  as  a  different  disease  from  enteric 
fever  arising  from  drinking  polluted  milk. 

The  view  that  mere  chemical  poisoning  is  the 
causative  agent  in  shell-shock  has  nothing  to  recom- 
mend it.  Suggestion  in  any  form,  whether  the 
patient  is  awake  or  under  hypnosis,  could  not  remove 
the  poison,  but  it  may  immediately  relieve  the 
symptoms.  In  what  way  shell-shock  or  poison,  as 
auto-mimicry,  is  a  contributing  factor  is  pointed  out 
later  on  (p.  48).  And  from  that  point  of  view  the 
shell-shock  may  be  said  to  be  the  causal  agent :  that 
is  to  say,  had  there  been  no  shell  there  would  be  no 
concussion  and  no  subsequent  hysterical  mimicry  of 
that  concussion  ;  but  equally  of  course,  if  we  trace 
the  sequence  further  back,  we  should  say  if  there  had 
been  no  war,  etc.,  or  if  the  Kaiser  ....  and  so  on 
ad infmitum. 

We  agree  with  Grasset1  that  it  is  "la  presence 
et  la  predominance  de  Pelement  psychique"  upon 
which  the  emphasis  should  be  laid  in  these  affections  ; 

1  Loc.  cit.  p.  105. 


INTRODUCTION  5 

hence  the  term  psycho-neurosis.  Wiltshire2  con- 
cludes that  "any  psychic  shock  or  strain  may  cause 
a  functional  neurosis,  provided  it  be  of  sufficient 
intensity  relative  to  the  nerve  resistance  of  the  indi- ' 
vidual.  Such  shock  or  strain  need  not  have  any 
connection  with  "sex  complexes." 

The  term  functional  disease  is  a  very  good  one 
if  it  be  understood  that  we  have  primarily  an  inter- 
ference with  function,  which  may  or  may  not  produce 
secondarily  a  structural  change.  This  is  in  sharp 
contrast  with  the  organic  diseases  where  the  primary 
lesion  is  structural,  the  interference  with  function 
being  secondary.  A  fracture  of  the  femur  inter- 
feres with  the  function  of  the  leg,  a  wound  of  the 
musculo-spiral  nerve  interferes  with  the  function  of 
the  hand,  but  the  interference  with  function  is 
consequent  on  the  structural  changes.  In  a 
hysterical  paralysis  of  the  leg,  in  hysterical  wrist- 
drop,  no  primary  organic  lesion,  macroscopic,  micro- 
scopic, muscular,  or  bio-chemical,  need  be  postu- 
lated. We  can  account  for  these  conditions  by 
psychological  laws.  In  doing  so  we  must  exclude 
altogether  physical  terms,  brain-cells,  movements 
of  dendrites  and  the  like.  This  is  not  the  place 
to  examine,  as  I  hope  to  do  in  another  book,  the 
relationship  between  mind  and  body  placed  by 
recent  psychological  work  upon  a  more  scientific 
footing ;  it  must  be  sufficient  to  say  that  against  the 
very  current  dogma  that  disease  is  inconceivable 
without  some  underlying  physical  basis,  the  dogma 
in  this  little  book  is  that  some  diseases  are  con- 
ceivable without  any  underlying  physical  basis ; 
mens  peccat,  non  corpus.  The  evidence  for  this 
statement  will  be  found  in  the  psycho-pathology 
of  the  diseases  which  are  treated  (Chapters  III,  IV 
and  V).  To  prevent  misunderstanding  the  corollary 

2  Loc.  cit.  p.  1,  212. 


6  WAR-SHOCK 

may  be  added  that  some  diseases  are  inconceivable 
without  an  organic  basis. 

The  dogma  at  the  back  of  this  book  does  not  stand 
upon  the  fashionable  doctrine  (less  fashionable  to-day) 
of  a  psycho-physical  parallelism.  The  use  of 
terms  such  as  region  of  the  mind,  passing  into  the 
unconscious,  and  so  on,  which  would  imply  that  the 
mind  is  extended,  are  to  be  regarded  as  figurative;  I 
could  not  omit  these  terms  without  troublesome 
paraphrases  and  a  full  explanation  of  the  doctrine 
that  the  mind  has  relationship  to  time,  whilst  matter 
(here  as  brain  and  nervous  system)  is  related  to 
space. 

Though  the  influence  of  mental  processes  upon  the 
body  will  be  the  chief  study,  the  action  of  physical 
processes  upon  the  mind  will  receive  notice.  Every 
physician  is,  of  course,  acquainted  with  and  makes 
use  of  these  reciprocal  actions  in  a  general  way. 
We  all  know  that  cheerful  surroundings  and  sympa- 
thetic understanding  can  occasionally  convert  physi- 
cal illness  "from  a  consuming  fire  into  a  gentle 
licking  flame,  and  make  it  thus  expire." 

We  must  also  recognise  that  physical  means  have 
sometimes  a  no  less  valuable  effect  upon  mental  states; 
Lord  Byron  was  not  singular  in  finding  a  dose  of 
salts  to  be  the  most  exhilarating  stimulant  in  moods 
of  depression. 

The  diseases  here  considered  are  hysteria  and 
psychasthenia.  I  have  excluded  the  term  neuras- 
thenia altogether,  because  I  am  unable  to  find,  at  any 
rate  in  the  troubles  produced  in  the  war,  any  clinical 
entity  that  corresponds  to  this  term.  Beard,  who 
baptised  this  disease,  defined  neurasthenia  as  a 
"chronic,  functional  disease  of  the  nervous  system, 
the  basis  of  which  is  impoverishment  of  nervous 
force,  waste  of  nerve  tissue  in  excess  of  repair  ;  hence 
the  lack  of  inhibitory  or  contributory  power — physi- 


INTRODUCTION  7 

cal  and  mental — the  feebleness  and  instability  of 
nerve  action  and  the  excessive  sensitiveness  and 
irritability  local  and  general,  direct  and  reflex."3 
It  is  not  any  stickling  for  etymological  rectitude  that 
gives  rise  to  an  objection  to  the  term.  It  is  the 
impossibility  of  apprehending  the  disease.  Beard 
already  included  in  his  book  a  mass  of  symptoms, 
obsessions,  phobias,  hysterical  manifestations,  to 
which  later  writers  have  added.  Neurasthenia  is 
now  frequently  an  euphemism  for  insanity  in  a  patient 
where  for  some  reason  or  other  the  word  insanity 
must  not  be  or  is  not  mentioned ;  it  is  not  without  its 
danger  when  thus  used.  In  colloquial  usage,  much  as 
the  laity  speak  of  a  nervous  breakdown,  or  of  rheu- 
matism, or  a  touch  of  the  gout,  or  a  chill  on  the  liver, 
the  word  no  doubt  will  continue  to  find  useful 
employment. 

Freud4  has  dealt  with  the  difficulty  by  giving 
the  name  neurasthenia  to  the  following  syndrome : 
exhaustion,  mental  and  physical ;  depression,  pressure 
on  the  head,  spinal  irritation,  and  dyspepsia.  "Accord- 
ing to  Freud's  views  this  clinical  picture  corresponds  to 
the  specific  cause  of  excessive  masturbation  or  frequent 
pollutions,  or  better  expressed,  neurasthenia  [as  thus 
limited]  may  in  every  case  be  traced  back  to  a  con- 
dition of  the  nervous  system  which  has  been  acquired 
through  excessive  masturbation  or  arisen  spontane- 
ously from  frequent  pollutions." 5 

I  have  not  found  this  simple  syndrome  among 
soldiers;  not,  of  course,  that  masturbation  does  not 

3  "A  Practical  Treatise  on   Nervous   Exhaustion  (Neuras- 
thenia)," by  G.   M.   Beard,  A.M.,  M.D.  New  York;  Second 
Edition,  1880,  p.  115.     His  first  paper  with  the  term  neuras- 
thenia was  published  in  1869,   in  the  Boston  Medical    and 
Surgical  Journal. 

4  "  Neurosenlehre.    Sammlung  kleiner  Schriften,"  Vol.  I. 
1893-1906.     Leipzig  and  Vienna :  Deuticke. 

5  "  Freud's  Theories  of  the  Neuroses,"  by  Dr.  E.  Hitsch- 
mann,  translated  by  Dr.  C.  R.  Payne.     New  York,  1913,  p.  15. 


8  WAR-SHOCK 

occur  among  them;  many  of  them  are  at  the  adoles- 
cent age  when  masturbation  is  common  enough,  and 
I  have  had,  of  course,  soldiers  addicted  to  masturba- 
tion or  complaining  of  frequent  pollutions.  But  it 
has  not  in  them  given  rise  to  neurasthenia  as  thus 
defined.  Case  100  (see  p.  100)  would  at  first  sight 
seem  to  be  an  instance  of  this,  since  the  only  symptom 
for  which  he  was  sent  into  hospital  was  exquisite 
fatigue ;  but  psycho-analysis  revealed  a  very  different 
picture  from  that  given  by  Freud.  I  do  not,  of 
course,  suggest  that  Freud's  neurasthenia  does  not 
exist,  only  that  I  have  not  come  across  it  among 
soldiers.  Freud  split  off  from  Beard's  neurasthenia 
another  group  of  symptoms,  the  anxiety-neurosis. 
This  again  I  have  not  found  in  its  pure  state  among 
soldiers,  whilst  his  other  clinical  picture  of  anxiety- 
hysteria  is  common. 

I  have  followed  Freud  in  dividing  hysteria  into 
two  groups. 

A.  Conversion-hysteria,  which   includes  the  affec- 
tions of  the  senses  and  locomotion,    fits,  and  so  on. 
Here  the  mental  affection  is  converted  into  its  physi- 
cal equivalent. 

B.  Anxiety-hysteria,  where  the  condition  of  dread, 
anxiety,  fear,  is  the  prominent  symptom  and  is  due 
to   some    repressed    unconscious    mental    complex. 
The  association  of  this  condition  with  vaso-motor  and 
other  symptoms  is  dealt  with  in  Chapter  IV. 

Psychasthenia,  which  to  some  extent  corresponds 
to  Freud's  obsessional  neurosis  (Zwangsneurose), 
is  the  other  psycho-neurosis  which  is  found  among 
soldiers ;  clinically  the  cases  correspond  very  well  to 
Janet's6  description:  "Les  psychastheniques  .  .  . 
preseatent  un  abaissement  de  la  conscience  dans  sa 
totalite  .  .  .  Cet  abaissement  general  qui  n'est  pas  com- 

6  Pierre    Janet.       "Les  Obsessions  et  la  Psychasthenie." 
Vol.  I.,  p.  675.    Alcan:  Paris.  1903. 


INTRODUCTION  9 

pense  par  un  retrecissement  du  champ  de  la  conscience 
leur  donne  des  sentiments  d'incompletude  bien  plus 
accentues  qu'ils  ne  sont  d'ordinaire  dans  1'hysterie." 
Obsessions,  imperious  acts,  phobias  and  various  phy- 
sical stigmata  characterise  the  psychasthenic. 
On  the  above  classification  my  100  cases  show: 

Conversion-Hysteria        ...       77 
Anxiety-Hysteria  ...          ...        17 

Psychasthenia        ...         ...         6 

100 

Most  of  the  cases  in  the  group  of  anxiety-hysteria 
correspond  to  cases  included  by  Janet  among  his 
psychasthenics. 

This  book  does  not  treat  of  the  psychoses  as  found 
among  soldiers.  Having  had  charge  of  a  mental 
ward  in  connection  with  the  psycho-neurological  de- 
partment, some  investigations  were  able  to  be  made 
into  the  psychology  of  their  insanities,  although  the 
patients  were  with  me  for  too  short  a  time  to  obtain 
any  complete  knowledge ;  the  treatment  was  neces- 
sarily unsatisfactory  because  our  hospital  was  not 
fitted  out  for  mental  patients,  and  the  patients  were 
transferred  to  England  at  the  earliest  opportunity. 
Despite  these  limitations,  I  feel  justified  in  saying 
that  a  considerable  number  of  the  psychoses  occurring 
in  the  war,  first  attacks  with  a  good  psychological 
history,  bid  fair  to  become  entirely  well  under  proper 
treatment. 

I  have  not  seen  any  statistics  as  to  the  number  of 
psychoses  in  our  armies ;  it  may  be  of  interest  to 
mention  that  Alt 7  estimates  them  at  1/1000  in  the 
German  Army.  Hoche,8  on  the  basis  of  previous 

1  Zeitschrift  f.  die,  g.Ncur.  und  Psychatrie,  Bd.  12,  Heft.  1, 
p.  6. 
8  Ibid.    Bd.  11,  Heft.  5.  p.  330. 


10  WAR-SHOCK 

experiences  in  German  wars,  places  the  insane  to  be 
about  2/1000,  and  thus  in  an  army  of  <H  millions  he 
says  there  would  be  about  8-10,000  insane. 

Jung  has  divided  the  psycho- neuroses  into  (a) 
diseases  of  extraversion  (hysteria)  and  (£)  diseases 
of  introversion.  I  have  been  tempted  to  follow  him, 
but  my  analysis  of  many  of  the  cases  was  not  funda- 
mental enough  to  venture  here  on  this  difficult  path. 
A  broad  psychological  distinction  between  hysteria 
and  psychasthenia  can,  however,  be  made;  if  with 
Freud  we  may  say  that  the  hysteric  suffers  from  his 
past,  the  psychasthenic  suffers  from  his  future. 

Each  forward  step,  babyhood  to  childhood,  child- 
hood to  puberty,  puberty  to  adolescence,  is  fraught 
with  difficulties  for  the  psychasthenic ;  he  cannot  fit 
himself  into  the  real  world  which  his  unconscious  self 
has  already  foreshadowed.  However  clear  and 
urgent  is  the  need  for  adapting  himself  to  the  situa- 
tion which  his  mental  and  physical  growth  demand, 
when  it  comes  to  execution  his  mind  becomes  inert. 
To  avoid  the  difficulties  which  loom  so  tremendous, 
his  mind  busies  itself  in  the  creation  of  phantasies 
centering  round  the  past.  If  we  have  on  the  one 
hand  the  creative  impulse  in  man  which  transcends 
his  experiences,  we  have  on  the  other  hand  what  we 
may  call  creation  (libido)  in  opposition,  i.e.,  content- 
ment with  the  present,  basking  in  the  sun,  sloth — the 
deadliest  of  the  seven  deadly  sins.  This  mind  will 
form  a  thousand  difficulties  and  obstacles  to  its  on- 
ward path,  difficulties  and  obstacles  which  will  never 
be  ascribed  to  this  inertia,  but  will  be  invariably  put 
down  to  the  doings  of  other  persons  or  to  troubles 
arising  from  the  real  world.  It  is  discovered  that 

"Shades  of  the  prison  house  begin  to  close 
About  the  growing  boy." 

This    prison    house   becomes   the  incest   motif,    the 


INTRODUCTION  II 

"terrible  mother,"9 the  temptress,  the  serpent;  the 
fear  of  the  father.  The  child  has  gradually  to  wean 
itself  from  the  warm  family  life,  once  a  necessity  for 
its  very  existence,  to  acquire  spiritual  autonomy,  just 
as  it  has  had  to  gain  physical  independence. 

This  book  does  not  deal  with  the  more  fundamental 
problems  of  the  psycho-neuroses  and  the  relationship 
of  these  affections  to  more  normal  lives.  In  only  six 
cases  was  psycho-analysis,  the  only  method  with 
which  I  am  acquainted  that  lays  bare  the  innermost 
secrets,  carried  out  for  therapeutic  purposes.  That 
is  to  say,  in  only  six  cases  did  the  patient  learn  to 
make  the  diagnosis  of  his  condition,  to  realise  him- 
self in  any  measure,  to  arrive  at  an  understanding  of 
his  unconscious  complexes  and  conflicts.  Nor  was 
the  treatment  complete  in  any  of  these  six;  the 
necessities  of  military  medicine  did  not  permit  me  to 
keep  the  patients  long  enough  under  my  care  in 
Malta  for  this.  For  professional,  not  scientific, 
reasons  some  of  these  cases  are  not  published. 
In  the  other  cases  I  have  been  content  to  find  the 
psychological  explanation  of  the  mechanism  of  the 
symptoms.1  This  could  be  done  by  a  close  per- 
sonal relationship  with  the  patients,  allowing  them 
to  talk  at  their  ease,  asking  few  questions,  but 
gathering  their  life-history,  earlier  characteristics, 
their  dreams  past  and  present,  the  details  of  their 
symptoms,  and  their  mental  and  physical  condition, 
both  at  the  time  when  the  disease  occurred  and 
subsequently.  The  interpretation  of  the  knowledge 
thus  acquired  has  been  made  by  the  results  of  that 

9  See  "The  dual  mother  role"  in  Jung's  "  Psychology  of 
the  Unconscious,"  translated  by  Dr.  B.  M.  Hinkle.  New 
York:  Moffat,  Yard  &  Co.,  1916. 

1  This  explains  the  omission  of  the  full  history  of  No  81,  who 
had  a  fairly  complete  treatment  by  psycho-analysis  with  excel- 
lent result.  I  was  able  to  keep  this  patient  under  observation 
several  months  after  the  end  of  his  treatment. 


12  WAR-SHOCK 

psycho-analytic  work  which  we  owe  to  the  genius  of 
Freud. 

So  far  as  these  100  cases  of  psycho-neuroses  in 
war  are  concerned,  it  will  be  seen  that  sex  is  not 
the  only  factor.  Sex  is  often,  to  use  one  of  Freud's 
terms,  a  "  Deck-E-rinnerung,"  a  "  cover-memory  " 
to  conceal  something  more  momentous.  See  the 
analysis  of  cases  Nos.  99  and  100,  pp.  100-114  But 
in  some  cases  sex,  in  the  form  of  the  typical  QEdipus 
myth,  is  very  clearly  brought  out  (No.  26,  p.  74), 
whilst  in  other  cases  it  was  highly  probable  that 
adequate  psycho-analysis  would  have  laid  bare  a 
sexual  complex  which  again  would  have  shown 
to  be  itself  symbolic  of  the  individual's  mal- 
adaptation.  The  method  of  interpretation  upon 
which  I  had  to  rely  cannot  bring  these  deeper 
complexes  and  ultimate  aims  to  light.  The  deeper 
layers  of  conflicts  do  not  emerge  into  the  conscious 
until  the  more  superficial  complexes  have  been  dealt 
with  by  consciousness. 

Nor  is  it  just  funk,  as  one  neurologist  calls 
it,  that  gives  rise  to  functional  diseases;  the  part 
that  suppressed  fear  may  play  in  the  produc- 
tion of  hysteria  will  be  considered  later,  but  this 
is  quite  another  thing.  Among  the  many  mutes  I 
have  seen  it  is  rare  to  find  one  who  was  struck 
speechless  by  terror.  But  terror  is  not  funk,  or 
fear. 

A  few  instances  of  sex  perversions  have  been 
encountered,  but  none  happens  to  be  included  in  the 
first  100  cases.  I  have  no  evidence  to  confirm  a 
statement  made  by  Teuton 2  that  war  exercises 
an  important  influence  upon  the  sexual  life  in  its 
various  phases,  both  inhibiting  and  stimulating  it; 

2  Geschlechtsleben  und  Geschlechtskrankheiten  in  den 
Heeren  im  Krieg  und  Friede.  Berliner  klinische  Wochen- 
schrift,  Nos.  1—4.  1915. 


INTRODUCTION  13 

occasionally  there  is  a  pathological  increase  even 
to  the  production  of  perverse  sexual  tendencies  and 
actions.  He  says  that  the  stage  of  long  marches 
and  battles  and  the  trenches  offer  no  inducement 
for  sex-action,  but  during  camp  life,  and  especially 
after  the  occupation  of  large  cities,  there  is  abun- 
dant opportunity.  Juliusberger  3  finds  that  certain 
cases  of  absence  of  love  of  the  fatherland,  absence 
of  interest  in  the  war,  and  want  of  understanding 
about  the  war,  are  due  to  a  pathological  sexual 
infantility . 

As  careful  an  investigation  as  the  circumstances 
permitted  has  been  made  into  the  family  and  per- 
sonal antecedents  of  the  patients.  Whenever  there 
has  been  the  slightest  evidence  of  a  bad  family 
history  or  of  earlier  psycho-neurotic  trouble,  quite 
apart  from  any  actual  illness  or  "  break-down,"  dis- 
cerned either  in  the  preliminary  case-taking  or  in 
the  later  psychological  enquiry,  the  case  has  been 
set  down  as  having  pre-war  antecedents.  It  is  to  be 
noted  that  all  the  cases  of  psychasthenia  had  an 
antebellum  history.  The  analysis  shows  : — 

With  pre-war  history  (family  or  personal)       30 
Without     „         „         (  =  war-shock)      ...        70 

These  figures  contrast  very  strongly  with  those 
given  by  other  observers.  Laudenheimer,4  for 
instance,  says  that  out  of  52  cases  of  psycho-neurosis 
there  was  in  90  per  cent,  a  predisposition  either  by 
congenital  constitution  or  by  disease  acquired  before 
the  war.  Forsyth5  has  found,  "  In  all  cases  coming 
under  the  writer's  notice  with  symptoms  which  were 
more  than  mild  and  transitory  a  history  of  some 

3  Zur  Kenntniss  der  Kriegsneurosen,  Monat.  f.  Psych,  u. 
Neurologie.  38,  No.  15,  1915. 

4  Miinch.  med.  Wochenschrift,  No.  38.    1915. 

5  "Functional  Nerve  Disease  and   the  Shock  of  Battle." 
David  Forsyth  ;  Lancet,  Dec.  25th,  1915,  p.  1401. 


I4  WAR-SHOCK 

earlier  nervous  trouble,  slight  or  severe,  was  forth- 
coming." 

Mott6  says,  that  "  in  a  certain  proportion  a  little 
more  than  one-third,  the  cumulative  effects  of  stress 
of  active  service,  combined  with  repeated  and  pro- 
longed exposure  to  shell  fire  or  high  explosive 
projectiles,  apparently  had  induced  a  neurasthenic 
or  hysteric  condition  in  the  nervous  system  of  a 
potentially  sound  individual." 

Mott's  conclusions  are  for  cases  of  shell-shock 
only.  Taking  for  comparison  the  19  cases  of  shell- 
shock  alone  out  of  my  100  cases  the  following  figures 
are  obtained  : — 

With  previous  pre-war  history  (family  or 
personal)  ...  ...  ...          8 

Without  any  ,,  ,,  ,,  11 

Moreover,  the  estimates  given  by  Mott  and  Lauden- 
heimer  are  based  upon  the  anamnesis  ;  a  psycho- 
logical examination,  which  begins  when  the  anam- 
nesis ends,  brings  to  light  neuropathic  traits  un- 
suspected and  incapable  of  recognition  by  the 
methods  used  by  those  observers.  My  figures  are 
based  upon  a  psychological  examination  sufficient  to 
bring  out  any  latent  neuropathic  traits. 

Harry  Campbell7  says  that  it  is  chiefly  among 
the  unstable  nervous  systems  that  the  neuroses  are 
met  with  in  war. 

On  the  other  hand,  and  entirely  in  accordance  with 
my  own  results,  Elliot  Smith8  says:  "It  would  be  a 
gross  misrepresentation  of  the  facts  of  the  case  to 
label  all  the  soldiers  who  suffer  from  mental  troubles 
as  weaklings.  The  strongest  man  when  exposed  to 
sufficiently  intense  and  frequent  stimuli  may  become 

6  Transactions  of  the  Royal  Society  of  Medicine,  February, 
1916.    Sections  of  Psychiatry  and  Neurology,  p.  5. 

7  The  Practitioner,  May,  1916. 

8  Loc.  cit.,  p.  855. 


INTRODUCTION  IS 

subject  to  mental  derangement.  It  is  quite  common 
to  find  among  the  patients  suffering  from  shock,  senior 
non-commissioned  officers,  who  have  been  in  the  army 
for  fifteen  or  twenty  years  .  .  .  and  have  stood  this 
severe  strain.  Such  men  can  hardly  be  called 
weaklings." 

Nonne9  admits  that  the  hysterical  syndrome  is 
more  easily  aroused  by  adventitious  factors  than  was 
thought.  Mann l  agrees  that  the  healthy  can  become 
momentarily  hysteric,  and  Hoche2  contends  that 
every  combatant  can  become  hysterical  under  appro- 
priate experiences. 

Grasset 3  is  of  the  same  opinion.  "  Les  antecedents 
personnels  antebellum  et  hereditaires  ont  relative- 
ment  peu  d'importance  dans  le  developpement  des 
psychonevroses  de  guerre.  Ma  conclusion  serait 
differente  si  j'avais  a  m'occuper  des  psychoses  des 
guerres." 

Those  acquainted  with  the  works  of  Freud  and 
Jung  will  find  nothing  new  in  these  statements  which 
do  but  confirm  the  antebellum  findings  of  psycho- 
analysis. 

My  own  view,  founded  before  I  had  been  able  to 
consult  the  war  literature  on  the  subject,  was  expressed 
in  an  address  in  April,  1916,  to  the  Malta  Medical 
Conference,4  where  the  case  of  a  patient  suffering 
from  hysteria  consequent  on  severe  fighting,  for  which 
he  had  been  recommended  for  the  V.C.,  was  quoted: — 

"  In  most  cases  the  neurosis  has  arisen  under  the 
strain  of  quite  extraordinary  conditions.  I  would 
remind  you  that  our  Army  is  not  composed  of  fight- 
ing men,  in  the  technical  sense.  The  men  come  from 

9  Archiv.  f.  Psych,  u.  Nerv.  56,  Heft.  1,  1915. 

1  Deuts.  Med.  Wochenschrift,  No.  4,  1915. 

2  Archiv.  f.  Psych,  u.  Nervenheil,  56,  Heft.  1,  1915. 

3  Loc.  cit.,p.  107. 

4  The    Psycho-Pathology  of   the  War  Neuroses.     Lancet, 
August  12,  1916,  p.  168. 


!6  WAR-SHOCK 

the  mill,  the  mine,  the  farm,  the  counting  house,  the 
country  house ;  every  trade  is  represented  and  every 
class.  Thus,  men  brought  up  to  a  quite  other  avocation 
are  suddenly,  with  scant  training,  called  upon  to  make 
a  new  adaptation.  In  the  stress  and  strain  of  their 
normal  life  they  would  probably  have  been  equal  to 
any  emergency.  But  for  some — among  the  very 
best — the  new  conditions  called  out  to  them  to  strain 
themselves  to  the  very  utmost,  and  this  was  just  a 
little  too  much.  .  .  .  Napoleon  used  to  say  that  the 
British  are  a  nation  of  lions  led  by  asses.  The  lion 
is  still  there,  and  let  me  remind  you  lest,  post  bellum, 
you  forget,  that  the  lion  is  just  our  old  friend,  the 
British  working  man.  Eighteen  months  ago  the 
hero  of  the  bayonet  wounds  (Case  No.  24)  was — a 
plumber!" 

It  should  be  remembered  in  connection  with  the 
comparative  large  number  of  well-seasoned  N.C.O.'s 
who  suffered  from  hysteria,  that  their  responsibilities 
in  this  war  have  often  been  very  great ;  that  many  are 
men  who,  having  left  the  army  after  fine  service,  had 
married  and  settled  down  into  good  positions.  Throw- 
ing up  these,  they  have  had  the  additional  anxiety  of 
feeling  that  at  their  time  of  life  they  may  not  be  able, 
should  their  positions  be  lost,  to  find  the  same  security 
for  their  families  and  themselves. 

It  should  not  be  difficult  to  understand  why  hysterical 
shell-shock  is  rare  among  the  seriously  wounded.  In 
these  patients  the  psychical  energy  is  sufficiently 
occupied  with  something  very  concrete  and  real ; 
there  is  none  to  spare  for  the  creation  of  phantasies 
and  the  conversion  of  these  phantasies  into  the 
hysterical  symptom. 

In  regard  to  the  common  statement  that  hysteria 
is  a  sign  of  degeneracy,  and  the  statement,  which  was 
not  made  in  Germany  but  by  writers  in  this  country 
who  claimed  to  speak  with  authority,  that  the 


INTRODUCTION  17 

English  people  are  "a  degenerate  race,"  it  is  worth 
noting  that  19  out  of  the  100  cases  were  Anzacs,  and 
the  majority  of  these  19  were  not  men  from  the 
cities  but  from  the  bush.  Unless  the  relative  pro- 
portions of  the  Anzacs  to  British  troops  employed  on 
the  Peninsula  were  known,  no  argument  can  be  drawn 
from  these  figures.  But  one  can  say  that  the  up 
country  Anzac  is  not  immune,  in  war  anyway,  from 
hysteria. 

And  this  again  is  in  accordance  with  the  pre-war 
expectations  of  those  who  understood  these  conditions. 

A  psycho-neurosis  occurs  in  two  kinds  of  persons, 
those  who  are  inherently  below  the  level  of  the 
civilization,  who  may  be  called  degenerates,  but  are 
more  properly  to  be  regarded  as  backwards,  and  those 
who  are  ethically  in  advance  of  their  age.  The  latter 
are  the  harbingers  of  a  new  world,  of  the  dawning 
civilization  which  may  only  (or  may  never)  materialise 
centuries  hence.  Hence  their  conscious  and  uncon- 
scious selves  are  in  constant  conflict.  It  is  the  lot  of 
the  neurotic  frequently  to  be  in  unstable  equilibrium 
by  reason  of  these  inner  conflicts.  Such  conflicts 
seem  to  be  necessitated  by  the  very  essence  of  man. 
In  so  far  as  to-morrow  will  be  like  to-day,  and  it  will 
be  so  in  regard  to  a  large  number  of  mental  pro- 
cesses, man  is  served  by  his  experiences ;  but  to  man 
is  given  the  gift  not  only  of  creating  something  in  the 
morrow  which  is  quite  unlike  to-day,  dissimilar  from 
his  experiences,  but  also  of  foreshadowing  that  new 
creation.  That  forecast  of  the  new  he  relates  to  his 
known  experiences  by  means  of  symbols,  with  some 
of  which  we  shall  deal  later. 

The  war  might  at  least  rescue  the  word  neurotic 
from  its  present  use  as  a  term  of  reproach :  without 
the  neurotic  the  mind  of  man  would  be  stationary. 
The  war  may  teach  those  who  have  not  already 
learned  the  lesson  by  what  slightly  graded  steps 


IS 


WAR-SHOCK 


the  normal  differs  from  what  we  call  the  abnormal. 

The  following  table  shows   the   results   of   treat- 
ment:— 

100  CASES. 


Treatment. 

Cured. 

Im- 
proved. 

No 
change. 

Total. 

Suggestion  under  hypnotism 

70 

7 

2 

79 

Suggestion  without  hypnotism    ... 

3 

2 

— 

5 

Suggestion  under  anaesthetic 

6 

— 

— 

6 

Psycho-analysis         

•* 
i 

4 

— 

5 

Other  methods           

— 

1 

1 

2 

No  treatment  (referred  for  diagno- 
sis etc.) 

F31 

3 

l°J 

80 

14 

3  [6] 

100 

Thus  out  of  97  cases  submitted  to  treatment,  80 
were  relieved  altogether  of  their  symptoms  and  14 
improved,  What  is  meant  exactly  by  cured  and  im- 
proved I  shall  discuss  in  the  final  chapter.  These 
results  were  obtained  under  conditions  which  were 
not  the  most  favourable  for  psychotherapy.  The 
patients  were  2,000  or  more  miles  from  home,  they 
did  not  know  whether  they  were  to  be  sent  back  to 
the  front  or  would  go  home  first.  Though  everything 
possible  was  done  in  the  way  of  entertainment  by  the 
residents  of  Malta,  this  island  could  not,  of  course, 
offer  the  many  attractions  arranged  at  home  nor  could 
our  make-shift  hospitals  vie  with  the  beauties  and 
amenities  of  such  places  as  Netley,  or  the  4th 
London  General  Hospital,  where  nerve  patients  are 
treated.  The  particular  hospital  where  my  patients 
were  sent  was  regarded  as  an  infectious  hospital,  and 


INTRODUCTION  19 

the  patients  for  some  time  were  not  allowed  out  of 
the  limited  hospital  grounds.  It  speaks  well  for  the 
patients,  I  think,  that  only  three  did  not  improve  in 
their  condition. 

The  next  chapter,  II,  describes  the  clinical  mani- 
festations of  conversion-hysteria;  chapter  III  the 
psychological  mechanisms  of  these  phenomena.  In 
chapter  IV  some  cases  of  anxiety- hysteria  are 
described  and  explained ;  chapter  V  deals  with 
psychasthenia  in  the  same  way.  The  last  chapters 
deal  with  the  general  diagnosis  and  treatment  of 
these  disorders. 


CHAPTER  II 

CONVERSION-HYSTERIA 

THE  war  has  enabled  us  to  see  examples  of  almost  all 
varieties  of  hysterical  symptoms,  varieties  which, 
indeed,  a  special  hospital  would  only  be  able  to 
exhibit  during  the  course  of  years.  So  protean  are 
these  symptoms  that  for  the  sake  of  easier  following 
it  becomes  desirable  to  classify  these  manifestations 
according  to  the  prominence  of  the  symptoms. 
A  useful  division  is  into 

A.  Conversion-Hysteria  (Freud),  where  the  somatic 
disturbance  focusses  the   attention  of  the  observer, 
and 

B.  Anxiety-Hysteria,  where  the  psychical  elements 
claim  pre-eminence. 

In  both  forms  it  need  scarcely  be  said  that  physical 
and  mental  symptoms  always  co-exist,  and  that  it  is 
the  mental  state  which  demands  explanation  and 
requires  treatment. 

This  chapter  will  be  chiefly  limited  to  describing 
the  various  somatic  disturbances,  leaving  their  psy- 
chological explanation,  the  psycho-pathology,  to  the 
next  chapter. 

SENSORY  SYMPTOMS 

My  experience  does  not  agree  with  that  of  Bins- 
wanger,1  who  says  that  pure  sensory  disturbances 

1  Hysterosomatische  Krankheitserscheinungen  bei  der  Kriegs- 
hysterie.  Monat.  f.  Psych,  u.  Neurol.,  38  Heft.  1,  2,  1915. 


CONVERSION-HYSTERIA  21 

were  not  found  in  true  cases  of  war-shock  (war 
hysteria) ;  disturbances  of  sensation  were  always 
accompanied  by  motor  disorders.  I  agree  with  Bins- 
wanger  in  his  conclusion  that  the  war  hysteric  is  not, 
in  the  majority  of  cases,  a  constitutional  hysteric. 
This  conclusion  is  sound,  but  not  so  the  premises; 
the  following  is  a  case  where  hyperaesthesia  was  the 
most  prominent  symptom. 

No.  3.2  A  corporal,  aged  37,  who  after  16  years  in 
army  service,  had  rejoined,  and  was  wounded  in  May, 
1915,  in  the  right  forearm,  left  nipple  region,  and  else- 
where. The  wounds  were  superficial  and  had  apparently 
quite  healed,  but  the  site  of  the  wound  on  the  chest 
remained  painful.  Some  months  later  the  scar  over 
the  left  chest  reopened,  and  when  it  again  healed  the 
pain  over  the  scar  was  so  severe  that  he  was  unable 
to  carry  his  equipment.  When  examined  some  eight 
months  after  the  original  injury  he  presented  a  scar 
3^  in.  long,  running  along  the  fifth  intercostal  space, 
with  its  inner  end  2  in.  from  the  sternum .  The  scar  and 
the  skin  immediately  adjacent  were  acutely  tender  to 
pressure — he  could  not  bear  the  slightest  touch  here. 
To  cotton  wool  touches,  universal  anaesthesia,  save  for 
a  small  area  below  inguinal  folds  on  both  sides,  a  patch 
1  in.  below  and  external  to  angle  of  left  scapula.  To 
pin  pricks  universal  analgesia  except  (1)  just  below 
left  scapula,  (2)  over  scar  and  area  2  in.  below  it, 
(3)  two  small  areas  in  lower  abdominal  region  on  a 
level  with  scrotum. 

It  will  be  seen  that  the  anaesthesia  and  analgesia 
were  almost  complete  and  that  the  zone  of  hyperaes- 
thesia was  strictly  limited  to  the  area  of  scar. 

Joint  sense  normal.  Pupils  normal.  Smell  normal. 
Hearing,  contact  L.,  Rt  at  3".  Vibration  sense  lost  in 
lower  limbs,  normal  elsewhere.  Reflexes  :  right 

2  The  numbers  refer  to  the  numbers  in  the  appendix,  p.  146 
where  a  summary  of  the  cases  will  be  found. 


32  WAR-SHOCK 

plantar  absent  at  toes  and  thighs  (were  present  at  a  later 
examination)  ;  the  left  normal ;  abdominal  reflexes, 
lower  absent — the  other  reflexes  normal. 

There  were  no  other  symptoms ;  there  was  no  other 
indication  of  disease  of  the  nervous  system.  The 
scar  and  the  skin  adjacent  were  removed  by  operation 
in  February,  1915;  the  wound  healed  by  first  inten- 
tion. The  operation  did  not  alter  the  condition. 
The  pain  was  still  present,  as  were  also  the  analgesia 
and  anaesthesia.  About  a  month  later,  ten  months 
after  the  wound  had  been  received,  the  patient  was 
treated  by  suggestion  under  hypnotism.  At  the 
second  sitting  the  symptoms  entirely  disappeared ; 
the  normal  sensation  returned  in  the  analgesic  area. 
For  several  days  the  corporal  was  rather  dubious 
about  the  pain  not  returning,  and  he  went  through 
various  manoeuvres  to  assure  himself  that  he  was  now 
all  right.  There  had  been  no  return  when  he  left 
the  hospital  some  time  later. 

General  over-reaction  and  hypercesthesia,  fol- 
lowing shell-shock,  has  been  described  by  Myers 3  in  a 
young  stretcher  bearer,  when  even  the  lightest  touch  of 
cotton  wool  on  the  limbs  or  head  produced  very  little 
movement  whilst  a  pin  prick  produced  a  series  of 
most  violent  spasms,  almost  amounting  to  a  convulsion. 

Analgesia  and  anaesthesia  are  very  common, 
though  more  frequently  accompanied  by  functional 
motor  disturbances.  This  is  not  invariable,  as  shown 
in  the  following  case  of  hemiancesthesia.  No.  1 
was  a  powerful  muscular  man  of  22,  formerly  a  collier. 
There  was  complete  left-sided  hemianaesthesia, 
together  with  atrophy  or  absence  of  the  subcutaneous 
tissues  on  the  left  side  of  the  face,  upper  part  of 
left  chest,  and  the  left  limbs ;  possibly  the  meta- 
carpal  bones  and  phalanges  of  the  left  hand  were 

3  Charles  S.  Myers.     The  Lancet.  March  18,  1916.     Contri- 
butions to  the  Study  of  Shell-Shock,    p.  608. 


CONVERSION-HYSTERIA  23 

smaller  than  those  of  the  right.  There  was  no 
muscular  wasting  and  no  loss  of  power  either  in  the 
left  arm  or  leg.  He  had  fractured  the  left  forearm 
three  years  previously,  and  attributed  the  lessened 
size  of  the  forearm  to  that  accident.  His  attention 
was  drawn  to  the  much  smaller  size  of  the  left  wrist 
by  a  mate  and  he  then  became  much  alarmed,  believing 
that  he  would  lose  all  power.  He  was  not  aware, 
until  examination  in  hospital,  that  other  parts  of  the 
left  side  were  also  smaller  than  the  right  side. 

A  similar  sensory  condition  was  shown  by  No.  2, 
a  corporal  with  over  seven  years'  service,  who  was 
admitted  for  persistent  headache  which  had  lasted 
for  nine  months.  He  had  been  "gassed  "  in  France, 
was  three  days  unconscious,  woke  up  with  bad 
headache,  and  began  to  vomit  "  nasty  green  stuff." 
After  three  months  he  went  back  to  the  front,  where 
he  complained  of  pain  in  the  chest  and  shortness  of 
breath,  "could  not  move  without  his  head  swinging 
round."  He  was  at  a  rest  camp  for  some  time  and 
then  went  to  Salonica.  The  headache  had  never  left 
him.  A  few  days  after  his  arrival  at  Salonica  he 
went  into  hospital,  and  after  a  month  was  sent  to 
Malta. 

Examination  showed  a  complete  left-sided  hemi- 
analgesia,  and  a  slight  degree  of  simple  myopic  astig- 
matism (vision  9  in  both  eyes  without  glasses). 
These  and  the  headache  were  the  only  symptoms. 
Suggestion  under  hypnotism  soon  relieved  the 
patient  of  his  headache,  the  hemianalgesia  disappear- 
ing rapidly,  and  the  patient  was  in  a  few  days  sent 
to  a  convalescent  camp.  Four  weeks  later  he  was 
well  and  about  to  return  to  the  front. 

Both  these  patients  were  right-handed  and  the 
hemianaesthesia  was,  as  is  usual  in  functional  diseases, 
on  the  left  side. 

More    commonly  the  sensory  is   associated  with 


24  WAR-SHOCK 

motor  disturbance,  as  in  the  following  case  of  left 
hemiplegia  and  complete  mutism. 

No.  21.  An  N.C.O.,  in  the  R.A.M.C.,  aged  36, 
who  had  seen  15  years'  service.  Four  weeks  before 
admission  to  Malta,  whilst  on  duty  at  a  hospital,  he 
suddenly  lost  consciousness ;  on  recovering  he  found 
he  had  lost  power  in  the  left  arm  and  leg.  Two 
weeks  later,  on  admission  to  a  hospital  ship,  he  had 
another  fit  and  on  recovery  found  he  had  lost 
speech. 

There  was  complete  left  hemianaesthesia,  including 
the  face,  strictly  limited  to  the  middle  line  anteriorly 
and  posteriorly. 

The  left  visual  field  was  contracted  and  there 
were  loss  of  hearing,  of  smell,  and  taste  on  the  left 
side.  The  tongue  protruded  to  the  left,  but  could 
be  moved  to  the  right  at  once  on  command. 
The  reflexes  were  normal.  The  dumbness  was 
absolute  ;  the  patient  could  not  whisper,  laugh  or 
cough.  But  he  heard  and  understood  everything  and 
could  write  perfectly. 

It  was  considered  advisable  to  relieve  the  symp- 
toms of  paralysis  and  mutism  as  soon  as  possible. 
The  patient  was  therefore  treated  by  suggestion 
under  hypnotism  a  few  hours  after  his  admission  to 
our  department.  Speech  and  normal  sensation  were 
recovered  at  once,  and  after  a  second  treatment 
on  the  next  day  the  free  movement  of  the  limbs  was 
obtained.  Naturally  the  patient,  who  was  a  highly 
intelligent  man  (he  was  about  to  get  a  commission), 
and  had  had  a  long  experience  in  the  R.A.M.C., 
had  taken  a  very  gloomy  view  of  his  condition. 
It  would  seem  that  the  aphasia  following  the 
hemiplegia  had  been  a  little  misleading,  but  of  course 
the  fact  that  the  hemiplegia  was  left-sided  and  the 
patient  right-handed  told  very  much  against  an 
organic  disease,  for  which  one  would  have  to  suppose 


CONVERSION-HYSTERIA  25 

a  lesion  of  the  right  hemisphere  of  the  brain,  fol- 
lowed two  weeks  later  by  one  of  the  left  side. 

The  following  instance  of  total  hemiancesthesia 
occurred  on  the  right  side  in  a  left-handed  soldier. 
Its  mode  of  development  is  of  interest. 

No.  £4,  a  soldier  aged  23,  was  with  23  men  in 
a  sap  which  was  attacked  by  some  200  Turks.  He 
and  a  sergeant  leaped  out  of  the  trench  and  engaged 
in  a  hand-to-hand  fight  with  the  enemy  who  were 
eventually  driven  off.  He  received  15  bayonet 
wounds  in  the  fight ;  seven  of  these  were  penetrat- 
ing; 14  of  the  wounds  were  on  the  right  side  of 
the  body.  When  examined  one  month  later  the 
wounds  were  all  healed,  but  the  fingers  of  the 
right  hand  were  semi-flexed  and  could  not  be 
extended  (claw-hand).  Col.  Purves  Stewart  had 
made  the  following  note :  to  pin  pricks  anaesthesia- 
analgesia  of  the  whole  right  upper  limb  as  high 
as  shoulder.  At  beginning  of  examination  patient 
felt  pin  pricks  at  wrist,  as  examination  continued 
the  boundary  of  anaesthesia  steadily  receded  until 
it  reached  the  shoulder,  by  which  time  the  pre- 
vious sensitive  spots  were  now  anaesthetic;  further 
examination  showed  a  complete  right-sided  hemi- 
anaesthesia. 

In  another  soldier,  No.  19,  aged  31,  paresis  of  the 
left  of  the  body,  with  complete  left-sided  hemianaes- 
thesia,  had  followed  an  attack  of  dental  neuralgia; 
he  had  been  through  the  Gallipoli  campaign  without 
other  injury  than  having  the  tip  of  a  helmet  taken 
off  by  a  piece  of  shrapnel. 

In  a  Welsh  lad  of  21,  with  loss  of  power  in  both 
legs,  the  anaesthesia  and  analgesia  extended  from 
toes  to  mid-thighs.  (Case  No.  10.) 

In  many  cases  the  sensory  affection  is  much  more 
restricted;  thus  in  a  soldier,  No.  23,  with  drop  wrist 
of  the  left  hand,  which  followed  two  days  after  receiv- 


26  WAR-SHOCK 

ing  a  slight  gun-shot  wound  of  the  right  hand,  the 
loss  of  feeling  and  pain  extended  to  1  in.  above  the 
wrist.  In  another  case,  No.  22,  with  limitation  of 
movements  of  elbow  and  inability  to  flex  the  fingers, 
the  anaesthesia  extended  to  1  in.  above  the  wrist. 

HYSTERICAL  CONTRACTURE   OF  KNEE. 

No.  32,  with  1^  years  service;  felt  great  pain 
in  the  back  and  in  the  right  leg  on  the  morning  of 
November  29th,  two  days  after  the  great  storms  in 
Gallipoli,  where  he  was  in  the  trenches  and  up  to 
the  chest  in  water.  He  was  admitted  to  hospital  on 
December  6th.  The  pains  in  the  back  gradually 
improved,  but  the  knee  grew  worse — flexed,  stiff, 
every  movement  being  attended  by  great  pain, 
especially  in  flexion.  He  was  confined  to  bed  and 
examined  by  the  late  Colonel  Barker,  A.M.S., 
under  an  anaesthetic,  when  no  disease  was  found. 
[The  increased  pain  on  flexion  was  against  the 
joint  being  tuberculous.]  As  his  condition  grew 
worse  rather  than  better,  he  was  sent  for  treatment,  on 
January  30th,  to  the  Psycho-Neurological  Department: 
a  skiagram  was  taken  and  showed  an  apparently 
normal  healthy  joint. 

On  the  31st  January  he  was  brought  into  deep 
hypnosis,  when,  under  suggestion,  he  readily  moved 
his  knee  in  all  directions.  That  afternoon,  after 
waking,  he  felt  no  pain  but  still  walked  with  the  knee 
bent.  The  next  day  he  was  again  hypnotised.  After 
getting  him  to  walk,  I  said  (he  was  an  Edinburgh  lad 
in  a  Scotch  regiment):  "Now  dance  a  Scotch  reel." 
He  stood  stock  still,  not  moving  a  muscle.  I  repeated 
the  suggestion,  but  got  no  response.  I  then  said: 
"  Now  waltz."  He  immediately  gave  a  very  credit- 
able performance. 

He  was  quite  cured,  no  further  treatment  was 
necessary,  he  went  to  a  convalescent  camp  and  so  to 


CONVERSION-HYSTERIA  27 

the  front.  The  explanation  of  his  response  to  the 
waltz  suggestion,  and  lack  of  response  to  the  Scottish 
dance  suggestion  is  that  he  had  learnt  how  to  waltz 
but  not  how  to  perform  a  reel ;  investigation  showed 
also  that  his  "  local  patriotism  "  was  divided  in  allegi- 
ance, his  mother  being  English,  his  father  Scotch. 

This  experiment  tends  to  show  that  the  suggestion 
must  be  one  to  which  the  subject  is  not  strenuously 
opposed,  and  helps  us  to  understand  why  criminal 
suggestions  are  very  rarely  effective.  If  the  criminal 
suggestion  happens  to  coincide  with  a  very  strong 
wish,  for  the  execution  of  which  only  courage  has 
been  lacking,  it  may  be  carried  out,  but  if  it  is  one 
which  evokes  opposition,  the  suggestion  as  a  rule 
fails. 

ASTASIA-ABASIA. 

In  other  cases  the  motor  symptom  may  exist  or 
persist  without  any  sensory  disturbances,  at  least  by 
the  time  the  patient  is  examined. 

No.  33.  A  corporal,  of  over  13  years'  service,  was 
riding  along  a  mountain  road  when  his  horse  backed 
and  fell  with  him  over  the  cliff.  He  probably  dropped 
some  five  feet  on  to  a  ledge.  He  lost  consciousness 
and  awoke  some  hours  later  in  a  hospital.  When 
seen  five  weeks  later,  sensation  was  everywhere 
normal.  The  grasp  of  the  left  hand  was  feeble.  The 
legs  could  be  moved  whilst  he  lay  in  bed,  but  he 
could  not  walk  or  even  stand  without  supporting 
himself  (astasia-abasia).  Treated  by  suggestion 
under  light  hypnosis,  he  was  at  once  able  to  walk 
and  quite  recovered  in  two  days. 

DISORDERS  OF   SPEECH. 

The  most  striking  occurrence  is  complete  loss  01 
speech — mutism.  This  seems  also  to  be  the  commonest 


28  WAR-SHOCK 

of  the  speech  disorders.  Out  of  my  own  16 
cases  there  were  ten  of  mutism,  three  of  aphasia,  and 
three  of  stammering.  This  mutism  may  be  associ- 
ated with  deafness  (four  out  of  ten),  and  may  be 
quite  complete.  Mott  says,  "about  one  in  twenty  of 
those  suffering  with  shell-shock  and  having  no  visible 
signs  of  injury  have  lost  their  speech,  and  yet  are 
quite  able  on  admission  to  write  a  lucid  account  of 
their  experiences."  * 

That  is  to  say,  the  patients  cannot  cough,  whistle, 
make  any  sound  when  laughing,  and  in  severe  cases 
there  is  difficulty  in  putting  out  the  tongue,  and  in 
one  case  of  swallowing  (Mott,  ibid}.  They  are  able 
to  express  themselves  well  in  writing,  their  reading 
is  not  affected.  Sometimes  they  speak  in  their  sleep 
or  under  an  anaesthetic. 

In  several  cases  (six  out  of  the  ten)  the  mutism 
followed  a  shell  explosion.  A  shell  burst  within  a  few 
feet  of  a  young  officer  (No.  42) ;  he  did  not  lose  con- 
sciousness but  his  speech  went  completely.  Another 
soldier  (No.  38)  gave  the  following  account:  "My 
mate  was  killed  a  yard  in  front  of  me  on  August  /th ; 
we  had  enlisted  together  and  been  together  all  the 
time.  I  was  in  the  trench  at  the  time.  I  lost  my 
head  that  day  and  the  sergeant  had  to  stop  me  from 
going  over  the  parapet.  Three  days  later  the  acci- 
dent occurred  to  me,  a  shell  burst  a  couple  of  yards 
away.  I  lost  consciousness.  Some  said  afterwards 
that  I  was  buried,  others  that  I  was  shot  upwards.  I 
did  not  recover  my  consciousness  till  five  days  later, 
when  I  found  myself  on  the  ship  going  to  Lemnos 
and  unable  to  speak." 

There  need  be  neither  shell-shock  (i.e.,  exposure  to 
forces  generated  by  high  explosives),  nor  burial  as  a 

4  Shell-shock  without  Visible  Signs  of  Injury.  Proceedings 
of  the  Royal  Society  of  Medicine,  Vol.  IX.,  No.  4.  Sections  of 
Psychology  and  Neurology,  p.  xvi. 


CONVERSION-HYSTERIA  29 

prominent  factor.  In  No.  40,  mutism  followed  a 
shrapnel  wound  of  the  leg;  the  wound  was  slight  and 
soon  healed,  but  the  mutism  remained  and  was  cured 
by  suggestion  under  hypnotism. 

The  right  hemiplegic  and  mute  R.A.M.C,  N.C.O., 
already  referred  to  (p.  24)  presented  the  same  absolute 
mutism  as  the  shell-shock  cases.  In  a  private  (No.  43), 
aged  2J,  the  loss  of  speech  occurred  36  hours  after 
receiving  a  kick  on  the  left  lower  jaw.  He  had  been 
admitted  to  hospital,  and  was  taking  part  in  a  sing- 
song, when  he  suddenly  found  he  could  not  utter 
another  sound ;  he  remained  dumb  for  three  days, 
when,  on  awakening,  he  was  able  to  whisper  to  the 
nurse  to  bring  his  breakfast.  This  case  is  discussed 
more  fully  in  the  next  chapter. 

An  Australian,  No.  37,  had  been  mute  and  deaf  for 
five  weeks  after  two  months'  service  in  the  Dardanelles ; 
he  had  been  in  the  support  trenches  and  was  of  course 
under  shell  fire  all  the  time,  but  had  not  himself  been 
exposed  to  explosions  in  his  immediate  neighbourhood. 

Sometimes  the  same  symptoms  have  been  present 
on  some  previous  occasion.  The  young  officer,  for 
instance,  had  some  months  before,  whilst  on  board 
ship,  lost  his  voice  for  two  hours ;  it  then  returned 
spontaneously.  The  mute  who  had  been  kicked  had 
recurrent  attacks  after  this  first  occasion ;  he  became 
very  excited  playing  cards  one  afternoon  ;  he  was 
winning  and  his  speech  left  him.  Another  time  he  had 
become  excited  at  church,  went  to  bed  in  the  ward 
feeling  rather  dizzy,  and  in  the  morning  speech  was 
quite  gone.  He  would  remain  mute  for  one  to  four 
days. 

No.  39,  a  soldier  who  was  mute  after  a  shell 
explosion,  had  been  a  miner.  Eight  years  before 
there  was  an  explosion  which  killed  his  brother  work- 
ing in  the  same  mine,  and  he  became  mute,  the  con- 
dition being  absolute  for  15  months,  when  speech 


30  WAR-SHOCK 

partially  returned.     It  took  another  three  months  to 
recover  entirely, 

APHONIA. 

In  some  cases,  instead  of  complete  loss  of  speech, 
the  patient  is  just  able  to  whisper,  In  No.  44,  this 
followed  an  explosion ;  he  was  blown  sQme  feet  into 
the  air  by  a  shell  but  was  not  rendered  unconscious. 
He  then  noticed  that  he  could  only  whisper.  In 
another  case  (No.  46),  the  only  one  of  the  kind  that 
came  under  our  observation,  the  condition  arose 
during  convalescence  from  typhoid  fever. 

STAMMERING 

May  be  the  primary  speech  defect  in  war- 
shock,  or  may  follow  mutism.  (Cases  of  stam- 
mering before  military  service  are  excluded).  In 
In  a  soldier,  No.  47,  of  six  years'  service,  stammering 
began  after  he  had  been  invalided  from  France  for 
gastric  trouble;  a  year  later  he  still  stammered,  and 
presented  some  vasomotor  symptoms,  tachycardia, 
and  fine  tremors  of  the  hands.  A  younger  brother 
(not  in  the  army)  was  also  a  stammerer. 

No.  48,  an  Australian,  aged  21,  was  on  board  a 
ship  that  was  torpedoed ;  he  was  not  hurt  but  received 
a  "mental  shock."  Fourteen  days  later,  whilst  in 
the  trenches,  he  began  to  stammer.  He  had  never 
stammered  before;  his  mother  and  mother's  brother 
stammered. 

No.  25  was  wounded  by  a  bullet  which  entered 
Y±  in.  to  left  of  mid  line  behind,  between  D1-D2 
spines;  exit  2  in.  external  to  left  nipple  and 
1  in.  above;  after  being  shot  he  was  first  helped  by 
a  mate,  then  walked  himself  for  half  a  mile.  He 
lost  consciousness  and  woke  up  the  next  day  to  find 
himself  in  hospital,  with  complete  loss  of  speech  and 
inability  to  use  his  right  hand.  He  remained  mute 
for  four  months,  his  speech  then  gradually  began  to 
recover  and  he  went  back  to  service ;  when  examined 


CONVERSION-HYSTERIA  31 

16  months  later  he  stammered  rather  badly ; 
there  was  paresis  of  the  right  hand  with  glove 
analgesia  and  anaesthesia.  He  could  not  use  his 
fingers  for  delicate  operations  like  shaving,  buttoning, 
or  putting  the  cartridges  in  the  rifle.  Under  treat- 
ment the  full  power  of  the  hand  was  soon  restored, 
the  patient  announcing  gleefully  a  few  days  after  his 
admission  that  he  had  shaved  himself  for  the  first 
time  for  16  months.  The  stammering,  however, 
did  not  mend  with  corresponding  rapidity. 

Generally  speaking,  the  apparently  most  serious 
speech  defects  are  those  most  rapidly  cured.  Out  of 
the  ten  cases  of  complete  mutism  nine  responded 
immediately  to  treatment,  as  did  one  case  of  aphonia 
(No.  44),  the  other  two  cases  of  aphonia  recovered 
24  and  48  hours  after  treatment,  whilst  treatment 
effected  far  less  for  the  stammerers ;  improvement 
occurred  in  one  (No.  25),  under  treatment  that  quite 
cured  the  palsy  of  the  hand. 

It  is  interesting  also  that  speech  can  be  re- 
covered despite  the  patient's  conscious  objection  to 
treatment.  In  No.  39,  where  the  disability  was  of 
six  weeks'  standing,  all  treatment  was  refused.  He 
would  not  consent  to  hypnotism  nor  to  being  placed 
under  an  anaesthetic.  He  wrote  that  God  had  cured 
him  without  a  doctor  on  the  first  occasion  and  he 
would  prefer  to  wait  for  a  natural  cure  this  time 
also.  It  was  pointed  out  that  he  had  suffered  18 
months  on  the  earlier  occasion,  now  he  could  get 
well  in  a  few  minutes.  Finally  he  assented,  but 
maintained  that  he  was  not  expecting  any  help.  He 
was  lightly  anaesthetized  and  suggestions  were  then 
made.  He  was  hardly  recovered  from  the  anaesthetic 
when  he  asked  the  nurse  in  a  whisper  for  a  glass  of 
water.  In  a  couple  of  hours  the  voice  was  normal, 
but  there  remained  hesitation  in  speech  and  loss  of 
memory  for  some  simple  words.  Suggestion  under 


32  WAR-SHOCK 

hypnotism,  carried  out  the  next  day  with  the  patient's 
hearty  consent,  restored  perfect  speech. 

WAR-AMBLYOPIA. 

Loss  of  sight  (the  retinal  anaesthesias  of  the  older 
clinicians)  may  be  partial  or  complete. 

PERSISTENT   AMBLYOPIA. 

No.  55.  In  1901,  in  South  Africa,  a  pebble  flung 
from  a  horse's  hoof  struck  the  right  eye,  and  its 
vision  has  been  defective  since.  He  was  discharged 
from  the  service.  On  the  6th  May,  1915,  at  Hellas, 
a  shell  burst  near  him  ;  he  was  knocked  down,  but 
not  unconscious.  An  hour  later  he  vomited  blood. 
He  returned  to  duty.  About  the  middle  of  June, 

1915,  the  vision  of  the  left  eye  began  to  be  defec- 
tive.   This  defect   had    progressed.     On  July   26th, 

1916,  examination  showed  :  pupils  equal  and  active  ; 
eye  movements  normal ;  tension  in  each  eye  normal. 

JL.  J* 

R  V  60  Hm  +  5.50  spl.         L  V  36  Hm  +  5.50  spl. 

After  homatropine  and  cocaine. 
RVc  +  4.50spl.  _6    LVc  + 4.00  spl.  c  6 

+  1.75  cyL  ex.  20/  =  60  +  2.50  cyl.  ex.  10/=36 

Fundi  normal. 

Fields  of  vision  concentrically  contracted,  especially 
in  the  left  eye.  (Fig.  I,  p.  34). 

He  was  later  on  treated  by  suggestion  under 
hypnotism ;  treatment  being  at  first  directed  mainly 
to  the  left  eye.  Ten  days  later  the  vision  was 

+  .3~c  J5         L  V  4-  3.85  c~  .6 

R  V  c  +  1.75  ex.  20  =  18  +  1.50  ex  10/  =  12 

The  visual  fields  were  as  shown  in  Fig.  2  5  (p.  35) 

5  For  the  report  and  the  perimeter  charts  I  am  indebted  to 
Capt.  A.  D.  Griffith,  R.A.M.C.  Specialist  in  Ophthalmology, 
Malta. 


CONVERSION-HYSTERIA  33 

A  feeble-minded  lad,15  who  was  wearing  dark  blue 
glasses,  without  which  he  said  he  could  see  nothing, 
I  found  reading  small  print  in  the  dusk.  His  vision 
was  R  and  L  =  ?4  with  his  own  dark  glasses ;  with 
neutral  tinted  glasses  from  the  test  case  he  could  not 
see  6/60. 

Probably  more  common  than  double  amblyopia  is 
unilateral  amblyopia;  I  shall  record  later  an  in- 
teresting example  of  complete  blindness  in  one  eye 
coming  on  very  suddenly  whilst  sniping.  Sometimes 
the  amblyopia  is  accompanied  by  photophobia  and 
intense  pain. 

Diminished  visual  acuity  is  seen  in  quite  a  number 
of  soldiers,  sometimes  without  previous  physical  dis- 
order, sometimes  following  injuries  which  may  be 
slight,  or  such  diseases  as  typhoid  or  dysentery.  If 
these  patients  are  not  rapidly  improving  under  the 
usual  general  treatment,  suggestive  therapy  generally 
clears  up  the  condition  in  two  or  three  days. 

No.  56  complained  of  bad  sight  and  blurring  of 
objects  in  October,  1915.  Admitted  later  to  Malta 
for  "rheumatic  pains  in  knees."  Vision  on  December 
29th,  1915,  was  R  V  =s65  L  V  =  &.  He  was  sent  to 
rest  camp  and  re-examined  on  March  16th,  1916,  R  V 
=  yts  L  V  =  a6ff.  Slight  astigmatism  not  improved  by 
glasses ;  fundi  normal.  After  psychotherapeutic 
treatment,  examination  showed  on  March  19th,  RV 
=  3$-  L  V  =  5.  The  right  eye  was  amblyopic  from 
disuse. 

The  hysterical  symptoms  were  not,  of  course,  always 
confined  to  the  eyes.  An  Australian,  No.  52,  with 
amblyopia  of  the  left  eye  was  also  paraplegic ;  he 
had  hemianaesthesia  of  the  left  side  of  the  body, 

6  This  case  is  not  in  the  Appendix  ;  it  is  not  included  in  the 
100  cases.  He  was  under  my  charge  in  the  mental  ward  which 
was  quite  separate.  The  "  functional "  patients  were  scattered 
among  the  general  wards. 


34 


WAR-SHOCK 


CONVERSION-HYSTERIA 


35 


36  WAR-SHOCK 

although  hearing,  smell,  and  taste  were  normal. 
The  patient  was  right-handed.  He  was  in  an 
extremely  "  jumpy "  condition  when  seen  three 
months  after  the  following  experience  : — 

"We  were  three  in  a  trench,  which  was  under  shell 
fire.  Two  were  standing ;  1  was  huddled  up.  Ob- 
server sang  out  that  a  shell  was  coming.  I  was  on 
the  ground  and  put  my  head  between  my  ankles. 
The  next  thing  I  knew  was  that  I  heard  them  saying: 
'  It's  no  use  digging  any  more,'  and  then  a  second 
shell  burst.  I  came  to  on  the  boat,  and  found  my 
left  arm  in  a  splint.  The  arm  had  not  been  fractured 
and  the  splint  was  taken  off  next  day,  but  I  had  been 
buried  under  seven  feet  of  earth.  I  was  unconscious 
about  half  an  hour." 

Although  there  was  no  history  of  an  earlier  break- 
down, there  were  plenty  of  traces  of  a  psychopathic 
disposition  ;  the  patient  recovered  rapidly,  but  he 
was  not  suitable  for  the  front  line. 

Hemeralopia  is  not  infrequent  in  a  mild  form, 
objects  being  less  distinctly  seen  at  night  than  formerly ; 
total  blindness  at  night  also  occurred.  In  an  albino7 
with  absence  of  pigment  in  the  eyes  there  was  also 
intense  photophobia;  according  to  the  patient's  state- 
ment there  had  been  no  trouble  with  the  eyes,  no 
hemeralopia  until  the  Salonica  campaign.  The  heme- 
ralopia  improved,  but  it  did  not  completely  recover 
whilst  under  treatment  (10  days).  Hysterical  stra- 
bismus has  been  also  observed.  Westphal 8  records 
the  following  extensive  hysterical  eye  symptoms. 
After  a  slight  injury  to  the  back  of  the  head  there 
occurred  ophthalmoplegia  externa,  which  alternated 
with  spastic  contracture  of  the  rectus  internus,  miosis 

7  Not  included  in  the  Appendix.  He  came  under  my  care 
when  having  temporary  charge  of  the  eye  department. 

8.  Quoted  in  Zeitshrift  f .  d.  gesammte  Neurologic  u.  Psychia- 
trie,  Bd.  12.  Heft  4,  1916.  p.  340. 


CONVERSION-HYSTERIA  37 

and  increased  reaction  to  light.  Further,  blepharo- 
clonus,  intense  contraction  of  the  visual  field,  central 
scotoma  for  all  colours,  convergent  spasm  in  any 
light,  analgesia,  aguisia,  with  convulsive  attacks 
when  excited,  pronounced  hysterical  state  and  inhibi- 
tion of  thought.  The  symptoms  were  dependent  on 
and  influenced  by  the  examination.  [Which  side  of 
the  head  was  injured  and  which  eye  was  affected  are 
not  stated  in  the  abstract.] 

DEAFNESS. 

Deafness  is  in  many  cases  associated  with  other 
symptoms.  I  have  already  alluded  to  its  occurrence 
with  mutism  and  hemiansesthetic  states. 

No.  49  was  blown  into  the  air  by  a  shell,  but  not 
rendered  unconscious.  He  immediately  became  deaf 
in  both  ears.  When  seen  a  fortnight  later  he  was 
completely  deaf.  There  had  been  no  previous  history 
of  ear  trouble,  and  nothing  on  examination  beyond 
a  little  cerumen  in  both  ears  (removed  without  any 
improvement  of  the  deafness).  The  sense  of  smell 
was  absent,  but  sight  and  taste  were  normal. 
Analgesia  of  the  head  and  upper  part  of  the  neck 
to  the  collar  line.  Speech,  writing  and  reading 
unimpaired.  Under  suggestion  in  the  waking  state 
the  patient  a  few  days  later  regained  his  hearing  as 
suddenly  as  he  had  lost  it. 

Commoner  than  partial  or  total  deafness  is  increased 
sensitiveness  to  sound ;  the  patient  starts  at  the 
slightest  sound,  he  seems  to  be  afraid,  as  it  is  said, 
of  his  own  voice. 

SMELL. 

Smell  may  be  absent  altogether,  as  in  the  deaf  man 
just  quoted,  or,  more  frequently,  it  is  absent  on  one 
side  and  that  usually  the  left  side.  As  in  most  of  the 
hysterical  disturbances  of  the  senses  this  is  associated 


38  WAR-SHOCK 

with  other  stigmata,  e.g.,  anaesthesia  of  the  correspond- 
ing side  of  the  body.  Hypersensitiveness  to  smell  is 
also  found;  some  horrible  smell  may  persist  in  the 
memory,  as  in  Mann's  case 9  of  trance  condition,  which 
followed  the  digging  and  filling  up  of  pits  for  masses 
of  corpses.  The  patient  could  hardly  react  to  exter- 
nal stimuli,  only  saying  from  time  to  time,  "  What  a 
smell — leave  me  alone," 

TASTE. 

Taste  may  be  entirely  lost  or  absent  on  one, 
pre-eminently  the  left,  side.  A  constant  "bad"  taste 
in  the  mouth  is  a  common  complaint.  An  Aus- 
tralian had  constant  pain  in  the  back  after  a  fall  from 
his  horse  in  camp.  This  got  better  and  he  had  then  bad 
abdominal  discomfort.  After  a  time  the  symptoms  dis- 
appeared, to  return  whilst  in  the  trenches  ;  they  finally 
left  him,  but  he  had  a  "nasty  taste  in  the  mouth." 
It  was  so  bad  and  his  appetite  and  his  general  health 
were  so  much  affected  that  he  was  sent  to  hospital. 
The  teeth  were  good,  nor  could  anything  be  dis- 
covered amiss  on  physical  examination.  The  choicest 
foods  having  failed  to  remove  the  "nasty  taste," 
recourse  was  had  to  suggestion  under  hypnotism.  The 
success  in  this  case  must  not  be  regarded  as  a  possible 
addition  to  the  normal  commissariat  arrangements. 

TICS. 

My  experience  agrees  with  that  of  others,  e.g., 
W.  Schmidt1  that  tics  are  more  especially  found  in 
the  muscles  of  the  face,  neck  and  shoulders. 

No.  60  had  a  slight  superficial  wound  of  the  right 
knee,  followed  the  next  day  by  pains  in  the  back  and 

9.  Mann.  Ueber  Granatexplosiven  Storungen.  Arcb.  f. 
Psychol.,  56.  Heft  1. 

1  Schmidt.  Die  paychischen  und  nervosen  Folgestande 
nach  Qranatexplosionen.  etc.  Zeitsch.  f .  d.  G-es.  Neurologie  und 
Psych.,  29.  H.  5,  1915. 


CONVERSION-HYSTERIA  39 

shoulders;  he  was  sent  into  hospital  for  "nervous 
debility."  In  addition  to  the  symptoms  of  anxiety- 
hysteria,  to  be  described  later,  he  had  a  twitch  of  the 
lower  jaw.  This  was  rather  slowly  depressed  and 
the  mouth  opened  with  a  sigh  as  if  about  to  yawn  or 
take  a  deep  breath. 

Spasms  occurred  at  irregular  intervals,  but  some- 
times two  or  three  times  in  a  minute  and  then  left 
off  for  10  minutes  or  longer.  Among  numerous  symp- 
toms was  diminished  visual  acuity,  ^  R.  and  L.  An 
officer  to  whom  this  man  was  most  attached,  and  whom 
he  had  known  in  England  before  the  war  (both  came 
from  the  same  place),  was  killed  alongside  him  in  the 
trenches ;  the  patient  had  seen  his  officer  gasping  for 
breath  in  the  death  agony.  To  use  his  own  words,  he 
"had  never  seen  such  sights  before."  This  neuro- 
mimesis  was,  it  need  scarcely  be  said,  quite  un- 
conscious. 

No.  59.  Blinking  of  the  eyes  followed  an  attack 
of  conjunctivitis  in  a  lad  of  19.  On  December  10th, 
Captain  M.  M.  Townshend,"  R.A.M.C.,  reported  his 
R. V  =  2?  and  L  =  SB  and  the  defective  sight  as  prob- 
ably due  to  the  constant  blinking,  since  he  was  quite 
unable  to  fix  on  anything.  The  fundus  was  normal 
and  there  was  less  than  a  +  2  error  of  refraction. 
There  being  no  improvement,  he  was  submitted  to 
psychotherapeutic  treatment  on  January  12th;  the 
blinking  stopped  at  once ;  on  January  14th  Captain 
Townshend  examined  him  again  and  found  V.  R. 
and  L.  =  6/6. 

No.  77  had  frequent  myoclonic  spasms  of  the  left 
face,  wrist  and  shoulder  girdle,  with  a  great  tendency 
to  elevate  the  left  shoulder.  It  was  as  if  he  were  con- 
tinually shrugging  one  shoulder.  This  patient  had 
contraction  of  the  field  of  vision,  absence  of  smell  and 
taste,  and  diminished  hearing  on  the  left  side,  together 
2  Specialist  in  Opthalinology  at  Hospital,  Malta. 


40  WAR-SHOCK 

with  complete  left  hemianaesthesia  and  analgesia.  The 
case  is  described  in  more  detail  on  page  ;  we  shall 
deal  with  other  instances  of  somatic  disturbances  in 
the  next  chapter  in  the  discussion  of  their  psycho- 
logical mechanisms.  It  would  be  wearisome  to  repeat 
the  clinical  pictures  of  the  functional  war-palsies 
which,  as  we  have  sufficiently  illustrated,  may  affect 
any  part  of  the  motor  or  sensory  system. 

GANSER  TWILIGHT   STATE. 

Hysterial  fits,  fugues,  autopsy  chic  amnesia  and 
somnambulism  will  be  discussed  more  fully  in  relation 
to  the  psychology  of  these  conditions  ;  here  a  brief 
clinical  account  of  one  such  case  will  be  given. 

No.  76  had  a  shrapnel  wound  in  the  right  calf; 
the  wound  was  not  serious  and  was  almost  healed 
when  he  came  under  observation  some  weeks  later. 
Shortly  after  his  admission  to  hospital  for  the  wound 
his  mind  became  a  complete  blank.  He  had  a 
strange  dazed  expression  ;  when  spoken  to  he  stared 
at  the  speaker  as  if  trying  to  gather  some  impression, 
and  would  then  shake  his  head,  making  some  irre- 
levant response.  It  was  difficult  to  make  a  satis- 
factory physical  examination,  but  one  could  be  satis- 
fied that  there  was  less  response  to  pain  on  the  left 
side  of  the  body  than  on  the  right  (probably  complete 
left  hemianalgesia).  The  reflexes  were  normal  and 
there  were  no  motor  disturbances. 

Speech  was  normal,  and  as  far  as  could  be  ascer- 
tained so  were  hearing  and  sight ;  taste  and  smell 
were  not  affected, 

Memory. — Personal. — The  patient  did  not  know 
his  name,  address,  whence  he  had  come,  that  he 
had  been  engaged  in  a  war,  where  he  had  been 
fighting;  he  had  no  recollection  of  going  to  school. 

Recognition. — He  could  recognize  the  use  of 
objects  ;  if,  for  example,  told  to  make  his  bed  or  put 


CONVERSION-HYSTERIA  41 

on  his  boots,  he  would  execute  the  order.  He  knew 
what  to  do  with  matches,  cigarettes,  and  so  on — 
there  was  no  apraxia. 

Response  to  questions  of  the  simplest  kind  could 
not  be  obtained. 

Have  you  got  a  pair  of  boots  ?     I  don't  know. 

Do  you  want  cigarettes  ?  I  don't  know.  (He 
would  take  them  when  offered.) 

How  many  fingers  have  you  ?     Four. 

Where  is  the  wound  ?     Don't  know. 

There  were  no  hallucinations,  and  the  patient  was 
able  to  find  his  way  about  the  wards  and  grounds  ; 
he  would  even  keep  appointments  correctly  with  me 
at  my  room,  so  that  in  a  practical  sense  he  was  not 
disorientated  as  to  time  and  space.  Ganser3  first 
called  attention  to  this  peculiarity  of  response  in 
certain  twilight  states  associated  with  hysterical  stig- 
mata, and  the  condition  has  been  since  frequently 
observed.  I  am  not  acquainted  with  any  case  where, 
as  here,  there  was  no  neuropathic  basis,  and,  to  a 
very  large  extent,  practical  sense  was  preserved. 

The  patient  made  a  complete  recovery  under 
hypnotic  suggestion. 

A  group  of  clinical  interest  is  provided  by  the 

AFFECTIONS   OF  THE  VEGETATIVE   NERVOUS 
SYSTEM. 

These  may  be  simple  or  multiple ;  of  the  former, 
hysterical  vomiting,  enuresis,  diarrhcea,  nervous 
indigestion,  and  the  soldier's  heart  demand  con- 
sideration here. 

HYSTERICAL   VOMITING. 

No.  65,  28  years  of  age,  began  vomiting  after  food 
in  August,  1915,  whilst  at  M.;  this  took  place  two 

3  Ganser.  Ueber  einen   eigenartigen  hysterischen  Dammer- 
zustand.    Archiv.  f .  Psychiatrie,  1898.     Bd.  30,  p.  633. 


42  WAR-SHOCK 

hours  after  food;  on  the  Peninsula  he  got  worse. 
He  continued  doing  ordinary  duty  till  November, 
when  he  was  sent  to  Malta.  Vomiting  had  now 
become  continuous,  nothing,  not  even  water,  could  be 
kept  down.  He  had  been  kept  in  bed  for  some  weeks 
and  various  diets  had  been  tried,  including  neglect 
(purposeful)  without  any  relief.  Examination  on  Feb- 
ruary 3rd,  1916,  showed  a  well-nourished  body  without 
any  signs  of  emaciation  or  physical  condition  to 
account  for  the  sickness.  The  anamnesis  disclosed 
that  the  vomiting  was  a  neuro-mimesis  from  identi- 
fication with  the  patient's  favourite  brother,  who 
suffered  from  frequent  "bilious  attacks"  attended 
by  vomiting,  in  many  of  which  attacks  the  patient 
had  acted  as  nurse  to  his  brother.  This  know- 
ledge was  used  in  suggestion  under  hypnosis.  The 
vomiting  ceased  on  the  third  day  of  treatment,  the 
patient  being  put  on  ordinary  diet. 

ENURE3IS. 

Enuresis  yielded  to  psychotherapeutic  treatment 
in  a  case  (No.  63)  where  the  condition  had  arisen 
after  joining  the  army;  in  another  case  (No.  67), 
in  a  patient  aged  20,  where  the  enuresis  had  existed 
as  long  as  he  could  remember,  no  improvement 
resulted. 

DIARRHOEA  AND  INDIGESTION. 

Diarrhoea  and  indigestion  are  most  frequently 
connected  with  other  vaso-motor  troubles ;  sometimes 
with  vomiting  (No.  64). 

THE  SOLDIER'S  HEART. 

As  Punch  says,  cardiology  "must  be  far  and  away 
the  most  popular  subject  at  the  present  time,"  and 
perhaps  many  of  my  readers  may  even  agree  with 


CONVERSION-HYSTERIA  43 

Punch,  who  had  "  an  idea  that  the  finest  experts  are 
not  attached  to  the  Medical  profession." 

The  particular  variety  of  the  soldier's  heart,  where 
perhaps  Punch's  non-medical  expert  may  be  more 
successful  in  her  treatment  than  the  professional 
adviser,  will  be  familiar  to  all  military  doctors. 
The  following  is  the  picture  given  by  Sir  James 
MacKenzie  4 : — 

"  When  we  see  the  soldiers  in  this  country  invalided 
because  of  heart  trouble,  we  find  a  good  deal  of 
variation  in  their  appearance  and  symptoms.  The 
face  is  often  lined  and  drawn  ;  many  are  spare  and 
thin  with  a  great  vaso-motor  instability,  as  shown  by 
the  manner  in  which  the  peripheral  circulation  varies — 
the  hands  and  fingers  at  times  going  pale  and  cold ; 
at  other  times  the  fingers  are  thick  and  red,  and  the 
nose  likewise  becomes  red  and  even  blue  with  slight 
exposure  to  cold.  If  they  have  been  treated  for  some 
months  by  rest  and  feeding,  some  become  pale,  fat 
and  scant  of  breath. 

"  The  chief  complaint  is  an  absence  of  the  feeling 
of  being  well — they  often  feel  out  of  sorts;  'rotten' 
is  a  term  frequently  employed.  A  sense  of  fatigue 
or  exhaustion  easily  induced  is  common  to  all. 
Breathlessness  on  moderate  exertion  is  frequent; 
pain  over  the  region  of  the  heart  less  frequent.  The 
physical  signs  are  variable.  The  heart's  rate  is  often 
not  increased,  in  some  it  is  persistently  increased,  as 
frequent  as  120  per  minute.  More  frequently  at  rest 
the  rate  may  be  quite  moderate,  but  exertion,  some- 
times slight,  may  produce  an  undue  rapidity,  and  it 
is  in  consequence  of  this  excitability  that  the  term 
'  irritable  heart '  has  been  used.  Murmurs,  systolic 
in  time  and  heard  in  different  regions,  are  frequent, 

4  Proceedings  of  Royal  Society  of  Medicine — Vol.  IV.,  No.  4. 
July  1916,  Therapeutical  and  Pharmacological  Section,  p.  28, 
el  seq. 


44  WAR-SHOCK 

while  an  increase  in  size,  usually  slight,  is  not  un- 
common. In  a  few  cases  there  is  a  slight  cedema  of 
the  legs.  The  mental  condition  is  somewhat  varied. 
Periods  of  depression  are  not  infrequent,  and  the 
patients  are  often  very  irritable.  They  accept  the 
view  that  they  have  something  wrong  with  their 
hearts  and  readily  yield  to  all  restrictions,  and  are 
often  content  to  lie  in  bed  and  brood  over  their  woes." 

MacKenzie  says  that  the  condition  is  not  really 
cardiac  in  origin,  but  is  "the  outcome  of  an  injury  to 
other  systems  as  well  as  the  heart,  such  as  the  cen- 
tral nervous  system."  He  recommended  that  these 
patients  should  be  treated  by  fresh  air  and  judicious 
exercise  in  the  open  air ;  fishing,  riding,  golf,  etc., 
for  those  who  could  afford  it,  bowls,  quoits,  or  skittles 
and  so  on  for  the  less  fortunate.  ' '  As  soon  as  signs 
of  improvement  are  shown,  the  soldier  should  begin 
drilling."  He  recognised  that  it  is  the  mental  con- 
dition of  the  patient  that  chiefly  requires  attention — 
to  take  the  patient  "out  of  himself;"  that  "the 
sense  of  exhaustion  is  the  predominant  symptom 
and  that  it  is  probably  vaso-motor  in  origin,  due  to 
the  irritation  of  the  cerebral  nervous  system." 

Freud 5  has  described  exactly  this  condition  occur- 
ring among  civilians;  it  may  be  the  chief  and  only 
symptom  of  anxiety -neurosis  and  anxiety-hysteria  ; 
disturbances  of  the  heart's  action,  palpitation  and 
brief  arrhythmia,  with  longer  attacks  of  tachycardia 
up  to  severe  conditions  of  cardiac  weakness,  the 
differentiation  of  which  from  organic  affections  of  the 
heart  is  not  always  easy,  attended  by  depression, 
anxiety,  and  other  mental  conditions.  A  special  and 

5  Freud.  "Ueber  die  Berechtigung  vender  Neurasthenie 
einen  bestimmten  Symptomencomplex  als  Angstneurose 
abzutrennen,"  "  Neurologische  Zentralblatt,"  1895,  No.  2. 

See  also"  Anxiety-Neurosis"  in  Selected  Papers  on  Hysteria, 
by  S.  Freud,  translated  by  Dr.  A.  A.  Brill,  New  York :  The 
Journal  of  Nervous  and  Mental  Disease  Publishing  Co.,  1912. 


CONVERSION-HYSTERIA  45 

unnecessary  name  (phrenocardia)  was  coined  by 
Herz  6  in  1909  for  this  same  condition. 

It  is  important  to  remember,  as  Ley  ton 7  has  pointed 
out,  that  the  soldier's  heart  may  arise  from  disease  of 
the  heart  or  disease  of  the  vaso-motor  system.  "  In 
some  cases  the  two  sounds  of  the  heart  were  of  equal 
intensity,  and  these  I  believe  were  suffering  from 
myocardial  alteration,  probably  of  toxic  origin.  In 
other  cases,  however,  there  was  no  alteration  in  the 
ratio  of  intensity,  and  in  these  I  am  under  the  impres- 
sion that  the  disease  was  of  the  vaso-motor  system. 
It  would  be  of  considerable  interest  to  determine  how 
far  the  observations  of  this  type  could  be  corroborated 
when  applied  to  very  large  numbers,  and  whether,  as 
predicted,  nervous  shocks  such  as  those  produced  by 
high  explosives  led  to  disturbance  of  the  vaso-motor 
system,  which  may  last  for  a  considerable  period, 
whilst  toxins  of  bacterial  and  other  origin,  such  as 
gases,  cause  disease  of  the  myocardium."  For  this 
disease,  of  course,  psychotherapy  would  not  be  the 
treatment.  We  will  describe  briefly  some  cases  of 
"soldier's  heart"  i.e.,  of  functional  heart  attacks, 
corresponding  to  MacKenzie's  picture,  which  were 
treated  and  cured  by  psychotherapy. 

No.  68.  An  Australian,  aged  23,  was  blown  up 
by  a  mine  in  a  trench,  knocked  some  yards,  and 
remained  unconscious  for  several  hours.  This  was 
not  his  first  "shell-shock."  Has  been  sleepless  and 
unnerved  ever  since ;  much  pain  over  the  heart. 
This  gets  worse  on  the  slightest  exertion,  his  heart 
then  beats  violently.  There  is  a  fine  tremor  of  the 
hands  (eight  per  second)  and  some  tremor  of  the  legs 
when  he  walks.  A  systolic  murmur  heard  at  the 
apex.  Physical  examination  otherwise  negative. 

6  M.  Herz.    "Die  sexuelle  psychogene  Herzneurose(Phreno- 
kardie)."    Vienna  :  Braumuller,  1909. 

7  Proceedings  of  Royal  Scy.  of  Medicine.    Loc.  rit.  p.  49-50. 


46  WAR-SHOCK 

The  patient  is  a  teacher  in  a  town  in  Australia 
where  he  was  born  and  where  he  has  lived  all  his 
life.  He  regards  fighting  as  an  ignoble  profession. 
He  enlisted  in  a  burst  of  enthusiasm,  but  has  regretted 
it  ever  since. 

So  much  for  the  conscious  attitude.  A  different 
attitude  was  shown  in  the  unconscious.  Here  we  had 
to  do  with  an  extremely  aggressive  and  primitively 
savage  type.  He  dreamed  of  attacks  upon  the 
Turks,  he  is  leading  on  his  men.  He  had  a  recurring 
phantasy  of  plunging  a  dagger  into  the  navel  of  an 
enemy  and  turning  him  round  as  upon  a  spit.  We 
had  no  means  of  giving  the  patient  the  excellent 
treatment  advocated  by  MacKenzie  but  by  the  help 
of  suggestion,  in  the  waking  state,  his  condition 
improved.  After  20  days  he  was  sent  to  a  con- 
valescent camp  and  rejoined  his  unit  six  weeks 
later. 

No.  70,  a  soldier  aged  31,  who  had  been  in  the  Galli- 
poli  campaign,  was  sent  into  hospital  for  "  rheumatic  " 
pains  in  the  legs.  He  suffered  from  sleeplessness, 
breathlessness  and  such  intense  exhaustion  that  "  lift- 
ing one  leg  in  the  bed  quite  does  me  up."  The  thyroid 
was  diffusely  enlarged ;  no  ocular  signs  of  Grave's 
disease.  Fine  tremors  of  the  legs.  No  other  signs 
of  disease  of  the  cerebral  nervous  system. 

The  blood  pressure  was  high,  160/90;  tachycardia, 
irregular  pulse,  no  displacement  of  the  heart,  and  no 
murmurs. 

Besides  the  vaso-motor  signs  mentioned,  there  were 
sweating  of  the  palms,  pollakuria,  occasional  diarrhoea. 

Under  hypnotic  suggestion  the  patient  was  in  eight 
days  able  to  get  about  and  his  symptoms,  the  ex- 
haustion and  sleeplessness,  disappeared.  The  tremors 
and  tachycardia  were  slower  in  removal,  but 
eventually  ceased.  It  was  my  opinion,  as  well  as 
that  of  other  observers,  that  the  thyroid  had  diminished 


CONVERSION-HYSTERIA  47 

considerably,  but  unfortunately  no  measurement  was 
taken  on  his  earlier  examination. 

We  shall  return,  however,  to  the  consideration  of 
enlargement  of  the  thyroid  when  discussing  the  other 
variety  of  hysteria. 


CHAPTER    III 

PSYCHOLOGICAL  MECHANISMS  IN  CONVERSION- 
HYSTERIA 

AUTO-MIMICRY 

THAT  the  hysterical  manifestation  is  frequently  a 
mimicry  of  symptoms  seen  in  others  is,  of  course, 
well  known.  It  is  also  to-day  understood  that  such 
mimicry  is  not  conscious.  It  is,  I  believe,  less  well 
recognised  that  the  hysteric  may  mimic  the  symptoms 
of  an  illness  from  which  he  has  himself  suffered. 
Ziehen  seems  to  have  used  the  term  auto-mimicry,  I 
presume  in  the  sense  in  which  it  is  here  employed, 
although  I  have  not  been  able  to  trace  the  passage. 
Gatti J  gives  a  case  of  this  kind  in  a  girl  who  in 
childhood  suffered  from  epileptic  fits,  and  at  the  age 
of  18  had  hysterical  attacks  which  mimicked  the 
earlier  epilepsy. 

The  following  cases  show  this  auto-mimicry  some- 
what clearly : — 

No.  20,  aged  21,  of  four  years'  service,  was 
admitted  on  March  14th,  1916,  to  hospital,  Malta, 
with  a  diagnosis  of  traumatic  epilepsy. 

The  following  history  is  as  given  by  himself.  In 
the  middle  of  November,  at  Gallipoli,  he  was  wounded 
in  the  left  side  of  the  head  and  at  the  back  of  the  head 

1  Lodovico  Gatti.  "II  fenomeno  di  auto -imitazi one  nelle 
associazioni  istero-organiche  "  :  Ri vista  italiano  di  Neuropato- 
logia.  1913,  Vol.  VI.,  p.  159. 


PSYCHOLOGICAL  MECHANISMS  49 

by  a  piece  of  shrapnel,  He  was  unconscious  for  five 
days  and  woke  up  as  he  was  being  taken  ashore  at 
Alexandria.  On  awaking  he  had  to  satisfy  himself 
by  looking  and  touching  that  he  had  not  lost  his  right 
arm  and  leg.  He  had  no  feeling  in  those  limbs  and 
was  unable  to  move  either  the  arm  or  leg  for  three 
weeks ;  the  leg  gradually  got  better  and  then  the  arm 
began  to  improve.  He  states  that  he  stammered  for 
some  days.  Two  operations  were  done  upon  him 
(nature  unknown,  probably  not  of  surgical  severity). 
He  remained  in  hospital  till  the  end  of  January,  the 
first  weeks  in  bed.  He  suffered  a  good  deal  from 
headache  (frontal).  On  leaving  the  hospital  he  says 
he  was  able  to  walk,  but  the  right  leg  was  weak ;  he 
had  no  power  or  feeling  in  the  right  arm.  From 
Alexandria  he  was  sent  to  camp  in  Mudros.  Here 
he  had  three  fits. 

1st.  About  first  week  in  February,  1915,  when, 
after  a  little  dispute,  his  "  head  went  dizzy"  and  he 
lost  himself.  The  orderly  told  him  he  was  violent ; 
he  does  not  know  how  long  the  fit  lasted;  it  was 
followed  by  a  headache. 

2nd.  About  February  20th,  he  was  in  a  billet  with 
some  others  when  again,  after  a  little  dispute,  his  head 
was  dizzy,  he  had  a  buzzing  in  both  ears,  and  on 
awaking  recalls  being  slapped  by  a  doctor. 

3rd.  At  the  beginning  of  March,  in  the  same  place, 
he  was  repairing  a  telephone  and  was  being  "hustled" 
by  the  driver  of  a  motor-lorry  outside ;  again  felt 
dizzy  and  buzzing  in  the  ears,  and  remembers  doctor's 
presence  on  his  awaking. 

In  none  of  the  fits  was  there  any  incontinence  of 
urine,  nor  did  he  hurt  himself  nor  was  the  tongue  sore. 

Only  after  the  first  fit  did  he  speak  of  a  headache 
following  the  attack. 

Examination  :  Patient  is  a  right-handed  man  of 
powerful  physique  ;  speech  and  articulation  normal. 


50  WAR-SHOCK 

There  is  a  small  circular  scar,  *4  in,,  over  the  left 
upper  temporal  region,  X  in«  behind  Rolandic  line 
and  2l/2  in.  vertically  above  tip  of  left  mastoid. 

Pupils  and  cranial  nerves  are  normal, 

The  fundi  are  normal,  as  are  the  visual  fields. 

There  is  anaesthesia  and  analgesia  of  the  right  side 
of  face  to  middle  line,  of  the  whole  of  the  right  fore- 
quarter  and  of  the  right  lower  limb  from  the  toes  to 
a  hand's  breadth  above  patella, 

Though  patient  does  not  feel  the  pricks  of  a  pin 
(the  pin  can  be  driven  and  left  in  the  skin),  when  told 
to  place  his  left  hand  (the  eyes  being  shut)  on  spots 
indicated  by  the  examiner's  hand,  he  is  able  to  locate 
with  his  hand  the  area  so  touched.  Grasp  of  right 
hand  is  feeble ;  the  leg  appears  of  normal  strength. 

Joint  sense  deficient  in  fingers,  wrist,  elbow, 
shoulder  and  toes  of  right  limbs. 

Astereognosis :  fails  to  recognise  hair-brush,  knife 
or  key  in  hand  or  foot. 

Gait  normal. 

The  right  hand  cannot  be  used,  e.g.,  cannot  hold  a 
spoon,  fork,  or  cut  with  a  knife. 

Reflexes:  supinator  and  ankle  jerks  are  present. 
No  ankle  clonus.  The  plantar  reflexes  are  present. 
Abdominal  reflexes  are  present  and  equal. 

The  muscles  of  fingers  and  wrist  react  normally  to 
faradism. 

X-ray  examination  showed  a  piece  of  metal  in  the 
diplce  immediately  beneath  the  scar. 

A  diagnosis  of  hysterical  (functional)  anaesthesia 
and  paresis  of  the  right  hand  was  made  from  the 
distribution  of  the  analgesia  and  the  electrical 
reaction.  The  fits  were  concluded  to  be  hysterical. 

But  that  the  patient  had  had  a  temporary  organic 
hemiplegia  immediately  following  the  injury  is  clear 
from  (1)  history,  especially  his  looking  and  touching 
to  see  if  the  limbs  were  present.  In  my  experience 


PSYCHOLOGICAL  MECHANISMS  51 

this  is  unusual  in  purely  hysterical  conditions,  in 
accordance  with  what  would  be  expected  from  the 
psycho-pathology  of  this  condition.  (2)  The  site  of 
the  injury  as  shown  by  the  presence  of  metal.  (3)  The 
disorder  of  speech  (stammering)  immediately  after 
the  injury. 

On  March  1 6th  suggestion  under  hypnotism  was 
carried  out,  when  the  analgesia  disappeared  from 
face,  right  shoulder,  and  leg. 

March  18th,  second  treatment  by  suggestion  under 
hypnotism,  analgesia  confined  to  forearm. 

March  23rd,  complete  disappearance  of  analgesia 
and  recovery  of  use  of  hand. 

The  patient  remained  perfectly  well  from  April  9th, 
when  I  last  examined  him. 

The  diagnosis  was  confirmed  by  Col.  Purves 
Stewart,  A. M.S.,  consulting  physician,  and  by  Col. 
Thorburn,  A. M.S.,  consulting  surgeon  to  the  Malta 
command,  who  also  agreed  with  me  that  surgical 
interference  was  unnecessary. 

The  first  hemiplegia  was  presumably  due  to  a 
haemorrhage,  following  the  shrapnel  wound ;  this 
rapidly  cleared  up  and  was  succeeded  (apparently 
without  a  break)  by  the  functional  hemianaesthesia 
and  paresis. 

Case  No.  31.  Aged  24.  l-j%  years  service;  was 
wounded  on  January  7th,  on  the  back  of  the  right 
wrist  and  right  side  of  face.  Both  wounds  were 
superficial  and  healed  in  about  ten  days.  The  day 
following  the  injury  the  left  hand  began  to  hang 
down ;  he  first  noticed  it  hanging  on  going  down  to 
the  boat  for  embarkation  to  Malta. 

Patient  is  a  right-handed  man. 

Examination  on  January  27th  presented  a  typical 
drop-wrist  of  the  left  hand.  There  was  analgesia  (to 
pin  pricks)  to  one  inch  above  the  wrist.  Supinator 
reflex  present.  The  wrist  cannot  be  extended  and 


52  WAR-SHOCK 

no  movements  of  thumb  and  fingers  can  be  performed. 
Movements  of  elbow  and  forearm  are  normal.  All 
the  muscles  of  hand  react  to  faradism.  There  is  a 
small  scar  on  dorsum  of  right  hand. 

The  patient  states  that  the  right  hand  dropped  a 
little  immediately  after  the  injury,  but  only  for  a 
short  while,  and  it  recovered  at  once. 

January  28th.  Treatment  by  suggestion  under 
hypnosis ;  readily  hypnotised  and  feeble  movements 
of  thumbs  and  fingers  obtained. 

An  attack  of  paratyphoid  interrupted  further  treat- 
ment till  March  16th  ;  in  the  meantime  the  movements 
of  fingers  and  thumb  became  slightly  more  extensive, 
but  the  wrist  could  not  be  extended.  Abduction  and 
adduction  of  fingers  were  quite  impossible. 

March  16th.  Treatment  resumed,  and  on  March 
28th  a  note  says  he  has  now  complete  movements  of 
wrist  and  fingers,  there  is  no  analgesia ;  the  grasp  is 
still  rather  feeble.  Massage  was  now  used  and  the 
full  power  of  hand  soon  restored. 

That  the  functional  disorder  occurred  on  the  left 
side  (and  not  on  the  right)  is  in  accordance  with  the 
rule  that  functional  disorders  are  preponderantly  on 
the  left  side  in  right-handed  persons. 

Here  we  again  see  that  the  hysterical  lesion  mimics 
the  original  physical  trauma. 

No.  22,  aged  23,  wounded  on  December  27th,  in 
Gallipoli,  by  a  shrapnel  bullet  at  the  left  elbow  ;  the 
wound  of  entry  being  1^  in.  above  and  1^  in.  in 
front  of  external  condyle ;  the  exit  wound  was  ^  in. 
above  and  1%  in.  in  front  of  internal  condyle, 
Bullet  track  crossed  beneath  tendon  of  biceps 
emerging  behind  the  brachial  artery.  There  was  no 
injury  to  the  bone. 

He  complained  of  pain  from  palm  of  hand  to  tips 
of  fingers. 

The  elbow  was  flexed  to  an  acute  angle  and  could 


PSYCHOLOGICAL  MECHANISMS  53 

be  only  slightly  extended  by  passive  movement  which 
caused  great  pain,  the  biceps  tendon  becoming  very 
tense.  He  could  not  flex,  without  great  difficulty, 
any  of  the  interphalangeal  joints ;  the  terminal 
phalanx  of  thumb  and  index  finger  could  not  be 
flexed  at  all.  Supination  was  fair. 

Analgesia  and  anaesthesia  extended  from  finger- 
tips to  one  inch  above  wrist,  on  both  aspects  ;  vibra- 
tion sense  was  lost  in  fingers  but,  not  in  radius  or 
ulna. 

All  muscles  of  forearm  and  hand  reacted  normally 
to  faradism. 

The  patient  is  a  right-handed  man.  He  says  that 
the  arm  jumped  up  directly  it  was  hit ;  he  at  first 
thought  he  had  lost  the  arm  ;  from  the  time  it  went 
up  he  had  been  unable  to  bend  it. 

He  was  first  hypnotised  on  January  27th,  when 
under  suggestion  he  was  able,  although  with  signs  of 
pain  and  resistance,  to  move  the  elbow  and  the  fingers 
more  freely.  The  analgesia  receded  and  was  present 
only  over  thumb  and  index  fingers  and  their  corre- 
sponding metacarpal  bones.  This  patient  was  under 
treatment  till  February  15th,  by  which  time  the 
analgesia  had  disappeared,  the  elbow,  wrist  and 
finger  movements  were  perfectly  restored.  He  still 
had  difficulty  in  flexing  the  distal  phalanx  of  thumb, 
but  he  was  able  to  bend  it  with  effort. 

From  the  position  of  the  wound,  and  the  immediate 
flexion  of  the  elbow  and  fingers,  it  seems  clear  that 
there  must  have  been  some  passing  injury  to  the 
biceps  tendon  and  the  median  nerve. 

This  passed  off,  but  the  "  memory "  of  the  pain 
persisted,  leading  to  a  mimicry  of  the  original  physical 
injury. 

The  relationship  of  shell-shock — of  the  physical 
injury — to  other  functional  affections,  such  as  mutism, 
has  a  similar  explanation.  The  explosion  produces 


54  WAR-SHOCK 

a  commotio  cerebri  causing  loss  of  consciousness  ; 
this  physical  condition  lasts  a  certain  time.  On 
recovery  there  is  a  hysterical  mimicry  of  this  condi- 
tion which  is  sometimes  complete,  when  there  is  entire 
loss  of  consciousness  with  amnesia  for  the  period  ; 
in  other  cases  it  is  less  complete — or  the  one  state 
may  gradually  pass  into  the  other — and  the  patient 
remains  partly  shut  off  from  the  external  world, 
dumb,  deaf  and  dumb,  paralysed  and  so  on.  These 
patients  are  mimes,  they  are  acting  the  part  they 
played  when  they  were  hit. 

Sometimes  (No.  36),  this  proceeds  from  a  wish  to 
remain  unconscious  (to  be  dead);  "he  would  rather 
die  than  have  to  go  through  it  all  again,"  as  this 
patient  put  it  to  me.  The  motive,  however,  varies 
and  we  shall  deal  later  with  some  of  these  motives. 

2 . — HETERO-MIMICRY. 

An  instance  of  the  more  common  form  of  neuro- 
mimesis  has  been  given  on  page  ,  in  the  corporal 
with  the  tic  of  the  lower  jaw,  a  mimicry  of  the  death 
spasm  of  an  officer  to  whom  he  was  devoted.  Another 
example  was  supplied  by  No.  65,  briefly  mentioned 
on  page  41,  whose  history  is  worth  a  little  further 
study. 

a.  Identification  with  a  brother. — No.  65,  a 
private,  28  years  of  age,  suffered  from  hysterical 
vomiting.  The  history  showed  identity  with  a 
brother,  who  suffered  from  some  form  of  gastric  trouble 
accompanied  by  vomiting.  This  favourite  brother 
had  often  been  seen  by  the  patient  in  these  attacks 
during  which  he  at  times  sat  up  all  night  with  him. 
The  patient  had  been  brought  up  in  an  orphanage 
till,  at  the  age  of  17,  he  was  discovered  by  this  much 
older  and  married  brother,  who  then  took  the  lad  to 
live  with  him  and  "  did  everything  for  me."  What  this 
"everything"  meant  here  may  be  gathered  from  the 


PSYCHOLOGICAL  MECHANISMS  55 

patient's  account  that  up  till  17  he  had  never  been 
allowed  out  by  himself,  he  had  never  been  into  a  shop 
to  buy  anything.  The  authorities  of  the  orphanage 
took  entire  control  of  the  children — in  this  case  until 
the  age  of  17.  Thus,  when  claimed  by  the  brother, 
the  lad's  entire  education  for  life  had  to  begin.  He 
was  really  a  child  emotionally,  still  very  backward — 
nor  can  I  say  that  he  had,  in  compensation,  been 
intellectually  stimulated.  His  brother  had  found  a 
trade  for  him,  and  he  lived  financially  free,  but  in 
other  ways  most  dependent  upon  the  brother  until  he 
enlisted.  He  remained  well  in  England,  and  on 
board  ship,  but  very  soon  after  arriving  at  Mudros, 
preparatory  to  the  Peninsula  campaign,  the  vomiting 
began. 

This  slight  sketch  of  his  life  will  show,  I  think, 
that  early  environment  was  adverse  to  the  man's 
acquiring  mental  self-dependence  ;  placed  under  the 
new  conditions  of  life  it  is  not  surprising  that  he 
developed  this  "sympathetic"  vomiting,  betraying 
his  need  for  the  brother,  the  helper  and  consoler. 

The  unconscious  imitation  of  another's  passions, 
dress,  language,  tricks,  illnesses,  is  an  endeavour  to 
identify  oneself  with  the  object.  Such  identification 
may  be,  of  course,  partial,  the  subject  identifying 
himself  with  the  object  in  some  particular  quality, 
often  symbolised  by  a  particular  piece  of  mimicry  ; 
in  other  cases  the  imitation  is  complete,  one  "plays 
the  sedulous  ape "  to  some  reverenced  or  adored 
personality.  In  this  soldier,  the  identification  with 
the  brother's  illness  had  a  further  significance  which 
was  brought  out  in  the  course  of  his  examination. 
If  he  were  ill  like  his  brother,  that  is,  if  he  were  the 
brother,  he  would  be  in  England,  not  fighting  in 
Gallipoli.  He  therefore  becomes  the  brother. 

b.  Identification  ivith  a  horse. — An  interesting 
instance  of  this  variety  of  hetero-mimesis,  which 


56  WAR-SHOCK 

plays  so  large  a  part  in  the  totems  and  taboos  of 
primitive  man,  was  furnished  by  a  patient  in  whom 
such  identification  managed  consciously  to  dispose  of 
a  very  natural  fear — fear  which  Charcot  called  the 
agent  provocateur  of  hysteria.  The  case  is  dis- 
cussed on  page  79. 

A  development  of  the  condition  shown  in  hetero- 
mimicry  is  the  identification  of  a  third  person  with 
the  loved  object.  A  hysteric,  for  instance,  still 
emotionally  under  the  influence  of  his  love  towards 
his  father,  will  find  in  some  other  more  or  less  suit- 
able (dramatically  suitable  we  might  call  it)  person 
all  the  qualities  bestowed  upon  his  father ;  he  identifies 
the  third  person  with  the  father  and  takes  up  the 
filial  position  towards  him.  The  bystander  may  find 
very  little  evidence  of  the  similarity  between  the 
father  and  the  other  person,  but  with  a  certain 
emotional  attitude,  with  the  need  to  possess  a  father, 
phantasy  will  bridge  all  the  difficulties.  Oh,  that  he 
were  my  father  !  Oh,  that  my  father  were  alive  ! 
soon  becomes — He  is  my  father  !  My  father  is  alive 
and  can  help  me  !  This  mental  process,  and  the 
importance  of  its  recognition,  has  been  dealt  with  by 
Freud  under  the  name  of 

TRANSFERENCE, 

a  good  instance  of  which  is  furnished  by  the  blinking 
boy,  No.  59,  p.  39. 

He  was  cured,  by  suggestion,  of  the  blinking  of  both 
eyes  and  amblyopia,  after  the  relation  of  his  history. 
His  father  was  an  immensely  powerful  man  who 
used  "  to  lift  horses  and  carts  with  his  teeth."  Every 
night  his  father  would  come  to  the  bedside  and  talk 
with  him,  bringing  him  presents.  When  the  patient  was 
aged  4,  his  father  was  brought  home  one  Christmas 
morning  by  the  police  ;  he  had  been  found  in  a  field 
unconscious,  with  an  injury  to  the  head  ;  he  died  a 


PSYCHOLOGICAL  MECHANISMS  57 

few  minutes  after  being  brought  home.  There  was 
strong  suspicion  of  foul  play,  but  nothing  was  dis- 
covered. His  mother  used  to  talk  to  the  boy  very 
much  about  his  father,  dilating  on  his  great  strength, 
his  goodness  and  tragic  end.  This  lad  had  been  four 
months  in  the  Peninsula ;  the  vision  of  his  father  was 
constantly  before  him,  especially  his  being  brought 
in  by  the  police,  and  the  death  scene.  He  tried 
to  think  of  something  else  and  tried  to  close  his  eyes 
to  avoid  the  sight.  The  blinking  is  thus  seen  to  be 
here  symbolical  of  a  desire  to  shut  out  a  visual 
memory  picture ;  it  is  common  enough  to  close  the 
eyes  when  any  gruesome  picture  looms  up.  The 
revival  of  the  memory  of  the  father,  the  strong  man, 
had  many  determinants.  It  took  him  back  to  child- 
hood, with  a  wish  that  the  strong  father  might  be  there 
by  his  side ;  then  the  enemy  would  be  overcome  and 
he  would  have  no  fear.  Again,  the  death  scene :  he 
was  strong  and  well  himself,  but  like  his  father  he 
might  be  killed  suddenly  and  by  some  unknown  hand. 
His  mother  would  not  know  any  more  about  the 
details  of  his  death  wound  than  she  did  about  his 
father's. 

This  history,  with  a  great  deal  more  about  his  home 
and  his  early  life — he  was  a  very  good  boy  and  took  all 
his  earnings  to  his  mother,  who  had  married  again 
since  his  enlistment — the  lad  related  to  me  amid  great 
emotional  distress.  He  burst  into  a  flood  of  weeping 
as  he  told  me  the  story — and  at  the  end  of  an 
examination  and  talk,  which  lasted  some  two  hours,  he 
was  cured.  The  blinking  ceased  forthwith ;  we  dis- 
covered subsequently  that  he  had  identified  me  with 
his  father,  and  transferred  the  feelings  he  had 
experienced  towards  his  father  to  me.  His  father 
was  not  dead  then,  his  father  was  alive  and  must  look 
after  him.  Doubtless,  the  air  habitual  to  a  middle- 
aged  paterfamilias,  my  sympathetic  interest  in  the 


58  WAR-SHOCK 

boy,  and  perhaps  a  something  in  my  personal  appear- 
ance, were  sufficient  to  set  the  boy's  mind  weaving  its 
phantasies  around  me.  I  may  add  that  during  the 
next  few  weeks,  when  he  remained  in  hospital,  his 
filial  attitude  to  me  (in  the  best  sense)  persisted,  and 
he  would  seek  my  opinion  and  prattle  with  me  about 
all  sorts  of  matters. 

SYMBOLIC  CONVERSION. 

This  patient,  by  his  blinking,  gave  expression  to 
his  unconscious  ideas  in  the  oldest  form  of  language — 
gesture.  It  is  to  Freud  that  we  owe  our  understand- 
ing of  the  meaning  of  these  symbolic  actions.  It  is 
in  the  unconscious  that  we  find  the  springs  of  action 
and  of  thought — a  region  (this  and  similar  terms  are 
used  figuratively)  of  the  mind  whose  rich  and  varied 
emotional  nature  we  are  beginning  to  appreciate — a 
region  less  under  the  control  of  the  conscious  intellect 
than  had  been  heretofore  supposed.  Emotions 
inhibited  from  transference  into  action  do  not  pass 
into  nothingness,  but  persist  in  the  unconscious,  often 
influencing  the  whole  life  of  the  individual  in  some 
distorted  and  irregular  way,  perhaps  biding  the  time 
till  opportunity  occurs  for  their  manifestation. 

No.  24.  The  Irish  soldier  with  the  15  bayonet 
wounds  (see  page  25)  had  a  functional  claw-hand 
(main  en  griffe). 

In  recounting  the  story,  which  he  did  with  much 
vigour,  I  noticed  his  repeated  and  emphatic  state- 
ment :  "  In  such  fighting  you  must  clutch  your  rifle 
very  firmly  and  never  let  it  go,  guarding  yourself 
all  the  time."  The  explanation  of  his  contracture 
becomes  obvious.  Grasping  the  rifle  was  the  very 
attitude  his  hand  still  assumed  ;  in  the  unconscious  he 
was  still  clutching  the  rifle ;  he  was  still  fighting  the 
good  fight,  and  this  desire  was  symbolised  by  the 
grasping  hand.  I  was  able  to  confirm  this  view  under 


PSYCHOLOGICAL  MECHANISMS  59 

hypnosis,  for  on  suggesting  to  him  that  the  fight  was 
over  and  he  could  let  go  the  rifle,  his  hand  imme- 
diately relaxed.  We  then  got  a  little  deeper  into 
the  meaning  of  this  persistence  of  the  unconscious 
desire  for  a  continuance  of  the  fighting  by  the 
patient's  remark  that  when  he  takes  up  a  thing  he 
likes  to  carry  it  through  to  the  best  possible  extent. 
He  especially  prided  himself  on  his  bayonet  work. 

The  following  is  one  of  the  many  dreams  he  related 
to  me: — 

"  /  saw  a  person  walking  along  a  muddy  bank. 
He  had  on  a  long  gown;  he  was  a  priest.  Some 
Turks  caught  hold  of  him,  only  they  were  dressed  in 
khaki;  they  were  going  to  torture  him  when  I  arrived 
with  others" 

This  and  other  dreams  suggest  there  was  a  still 
deeper  motivation  for  the  hysterical  symptoms  than 
I  have  given,  but  it  was  not  possible  to  penetrate 
into  this  as  the  symptoms  promptly  disappeared 
under  hypnotic  suggestion. 

THE    MEANING   OF    HEMIANALGESIA. 

Some  authorities,  following  Babinski,  consider  that 
hysterical  anaesthesia  is  produced  by  the  suggestion  of 
the  examining  physician ;  the  above  case  seems  to  be 
at  first  one  in  point.  At  the  beginning  of  the  ex- 
amination there  was  no  analgesia  at  the  right  wrist, 
but  on  re-examining  the  wrist  analgesia  was  present. 

The  fundamental  difference  between  an  organic  and 
a  hysterical  anaesthesia  is  this :  In  organic  anaesthesia 
there  is  interference  with  sensory  conduction  on  the 
physical  side ;  in  hysterical  anaesthesia  there  is  no 
such  interference.  Sensation  reaches  the  unconscious 
but  is  there  inhibited  from  reaching  consciousness. 
In  this  case  there  was  nothing  amiss  with  the  skin, 
the  sensory  nerves,  the  brain ;  in  fact,  the  uncon- 


60  WAR-SHOCK 

scious  did  feel  the  light  touches  and  the  pin  pricks  but 
refused  to  make  the  conscious  mind  aware  of  them. 

What  is  the  meaning  of  this  refusal  ?  The  anam- 
nesis showed  that  during  the  fight  he  felt  no  pain,  he 
did  not  indeed  know  he  had  been  wounded  until,  on 
being  taken  away  much  exhausted  after  his  exertions, 
his  attention  was  called  to  the  blood  coming  from 
him.  This  young  Irishman  was  a  highly  strung  young 
man,  sensitive  to  pain  as  he  admitted.  Had  his  con- 
scious self  felt  pain  on  the  battlefield  he  would  either 
have  had  to  retire  from  the  struggle  or  let  go  his  rifle 
and  be  killed.  The  whole  of  the  exposed  area  (the 
right  side  of  the  body)  was  in  this  case  not  admitted 
into  the  field  of  consciousness.  The  motive  was  the 
same  as  Nelson's  conscious  motive  in  putting  up  his 
telescope  to  the  blind  eye  at  the  Battle  of  the  Sound. 
Nelson  wanted  to  go  on  fighting.  So  did  this  soldier ; 
he  was  not  to  be  put  off  by  feeling  the  pain  from 
ever  so  many  bayonet  wounds.  He  would  not  allow 
himself  to  feel  pain. 

The  analgesia  disappeared  a  few  days  later.  Its 
revival  under  the  pin  pricks  of  Col.  Stewart  is 
readily  understandable.  The  unconscious  is,  as  will 
be  abundantly  shown,  archaic  and  primitive  ;  it  is 
not  finely  discriminating.  Here  it  did  not  distinguish 
the  harmless  pin  pricks  of  Col.  Purves  Stewart  from 
the  harmful  bayonet  thrusts  of  the  Turks.  It  took 
no  notice  of  the  first  prick  or  two,  but  as  the  jabs 
continued  up  the  arm  the  earlier  memory  was  revived 
and  the  unconscious  was  on  guard  :  The  Turks  are 
at  it  again  !  Returning  to  a  similar  experience  the 
unconscious  developed  the  same  mechanism  of  defence, 
whilst  the  perception  did  not  pass  from  the  uncon- 
scious into  the  conscious.  Counter  suggestion  soon 
restored  the  normal  condition. 

In  another  case,  one  of  vomiting  (No,  64),  this 
symptom  expressed  the  patient's  disgust  at  the  scenes 


PSYCHOLOGICAL  MECHANISMS  61 

he  had  witnessed  in  war  ;  "loathsome"  was  the  word 
he  constantly  used  to  me  in  describing  these  scenes. 
The  expression  "  sick  with  horror "  is  more  than  a 
metaphor.  In  my  patient  it  expressed  physically  his 
repugnance  to  war. 

ANALGESIA  AS  AN   AN/ESTHETIC. 

Another  motive  for  the  anaesthesia — where  ignor- 
ance is  bliss — is  shown  in  No.  1  (see  p.  22),  where 
the  anaesthesia  prevented  any  direction  of  the  patient's 
attention  to  the  affected  side ;  a  defence  mechanism 
which  prevented  worrying.  The  patient  had  always, 
in  his  own  words,  been  as  strong  as  anything,  and  never 
ailed  a  day — barring  the  accident.  Under  hypnosis 
the  suggestion  that  he  could  feel  normally  every- 
where was  at  once  responded  to.  There  was  no 
motive  in  maintaining  the  anaesthesia  now  that  the 
patient  had  discovered  his  own  trouble.  A  little  later 
he  began  to  have  sleepless  nights,  and  he  came  to  me 
complaining  of  a  change  in  his  character — irritation 
without  adequate  provocation.  This  was  the  result  of 
his  discovery,  for  having,  through  accidental  causes,  to 
be  kept  in  the  hospital  rather  longer  than  was  intended, 
he  assumed  that  he  would  be  discharged  unfit.  He 
was  reassured  and  remained  quite  well  during  the 
rest  of  his  stay  in  hospital  (10  days),  but  the  trouble 
is  not  unlikely  to  recur  in  other  forms. 

WHY   FUNCTIONAL   ANESTHESIAS   ARE  LEFT-SIDED. 

The  left  is  the  side  of  election  for  hysterical  mani- 
festations," in  war  as  in  peace.  It  may  be  said 
generally  that  if  the  hysterical  symptom  occurs  on 
the  right  side  there  is  some  particular  cause — the 
patient  is  left-handed  or  the  symptom  is  grafted  on 
to  some  earlier  or  still  existing  organic  defect,  or  the 

2  Purves  Stewart.    "  The  Diagnosis  of  Nervous  Diseases,"  4th 
Edition,  p.  392.     London :  Edwin  Arnold. 


62  WAR-SHOCK 

right  side  is  physiologically  adapted  to  the  psycho- 
logical motive. 

In  No.  24  the  patient  is  left-handed  and  the  right 
half  of  the  body  was  advanced  in  the  bayonet  fighting ; 
it  was  on  this  side  that  he  received  fourteen  out  of 
his  fifteen  bayonet  wounds.  In  such  cases  as  Nos.  2, 
19,  20,  21,  23,  the  selection  of  the  left  side  seems 
quite  arbitrary. 

Oppenheim3  attributes  the  greater  preponderance 
of  left-sided  over  right-sided  symptoms  to  the  rela- 
tively low  vitality  of  the  right  hemisphere  of  the  brain, 
a  statement  without  any  physiological  value  and  of 
course  having  no  psychological  meaning. 

Lewandowsky 4  suggests  that  the  left-sided  selec- 
tion has  a  psychic  factor — the  much  greater  incon- 
venience of  the  paralysis  of  the  right  side.  It  is, 
however,  to  Stekel's 5  analysis  of  dreams,  of  hysterical 
fits  and  giddiness  with  the  tendency  to  fall  on  the  left 
side,  that  we  must  look  for  the  full  meaning.  He 
pointed  out  that  right  and  left  are  used  not  only  of 
direction,  but  are  terms  denoting  mental  and  moral 
judgments.  We  say,  "  He's  all  right "— "  To  get  out 
of  bed  with  the  left  foot  foremost."  In  the  posters 
of  "The  Girl  who  took  the  Wrong  Turning,"  the 
artist  depicted  the  beautiful  but  naughty  heroine 
turning  to  the  left  at  the  cross-roads.  The  left-sided 
phenomenon  is  a  symbolical  expression  meaning  that 
things  are  wrong  with  one.  "Up"  and  "down" 
are  used  similarly  by  the  unconscious — we  speak  of 
a  fallen  woman,  an  elevating  book,  down  in  the 
dumps.  Every  observer,  of  course,  pays  attention  to 
the  general  bearing  of  his  patient,  noting  whether 
he  walks  with  an  erect  posture,  head  and  eyes 

3  Berl.  klin.    Wochenschrift.    November  3rd,  1915. 

4  Zeitschrift  fur  die  gesamte  Neurologic  und  Psychiatrie, 
1916.    Vol.  XII..  No.  4,  p.  427. 

5  Stekel,  W.    Jabrbuch  f.  psychoanalytische  u.  psychopath. 
Forschungen,  Vol.  I.,  p.  467. 


PSYCHOLOGICAL  MECHANISMS  63 

uplifted,  or  slouches  along  with  bent  back  and  down- 
cast eyes. 

SYMBOLIC    GESTURE. 

The  translation  of  mental  processes,  verbal  state- 
ments, moral  judgments  and  so  on,  into  their  physical 
equivalents,  plays  a  large  part  in  the  dream  mechanism ; 
it  is  worth  studying  some  other  instances  of  this 
process  in  hysterical  symptoms. 

No.  9.  An  Australian,  aged  36,  was  admitted  on 
January  24th,  for  stiffness  and  pain  in  the  back  and 
paraplegia.  The  sensory  and  motor  disturbances  in 
the  legs  improved  considerably,  but  the  back  remained 
as  stiff  as  a  ramrod  and  more  painful.  The  history 
he  gave  betrayed  much  feeling  at  what  he  considered 
inadequate  treatment  after  a  high-explosive  shell  had 
burst  some  yards  from  him  on  November  10th.  He 
walked  down  to  the  dressing  station  and  was  given 
some  pills  and  sent  back  to  the  trenches.  The  next 
day  his  back  was  painful,  but  he  says  he  showed  him- 
self to  the  doctor,  who  again  sent  him  back.  In  the 
trenches  he  was  unable  to  move.  On  the  fourth  day 
he  was  sent  into  hospital  and  thence  to  Malta. 

It  must  be  understood  that  I  am  repeating  this 
history  not  to  criticise  the  medical  officer,  nor  need  we 
accept  the  patient's  story  as  the  account  of  what 
really  took  place.  We  accept  it  for  its  psychological 
value — it  expresses  what  the  patient  felt  on  the 
subject,  a  feeling  which  gave  rise  to  much  emotional 
bitterness,  even  under  hypnosis.  The  clue  as  to  the 
meaning  of  this  rigid  back  was  obtained  one  day  when 
he  said  in  hypnosis  :  "  The  doctor  put  my  back  up." 
There  unfortunately  the  back  remained  when,  having 
recovered  the  power  of  his  legs,  he  was  sent  back  to 
Australia,  where  one  hopes  it  will  come  down  under 
the  mollifying  influence  of  his  wife  and  children. 

Another   instance  of   this  symbolism   occurred  in 


64  WAR-SHOCK 

No.  43,  the  case  of  recurrent  mutism  referred  to  on 
p.  29. 

This  is  the  lad  who  was  kicked  on  the  left  jaw  by 
a  horse  on  December  31st.  (He  also  complained  of 
inadequate  treatment.)  On  January  1st,  having  been 
then  admitted  to  hospital,  he,  whilst  in  bed,  was 
taking  part  in  a  sing-song  when  he  suddenly  found 
he  could  not  utter  another  sound.  He  remained 
dumb  till  the  morning  of  the  4th,  when  on  awaking  he 
found  he  could  whisper  that  he  wanted  his  breakfast . 

This  is  a  pretty  instance  of  one  of  Dr.  Gee's 
aphorisms:  "It  is  an  interesting  reflection  that 
powerful  emotion  promotes  eloquence  and  sometimes 
takes  speech  away."  Whether  the  patient  was  an 
eloquent  speaker  I  am  not  able  to  say,  but  I  presume 
he  was  something  of  the  sort ;  he  was  in  the  habit  of 
preaching  both  before  and  since  joining  the  army. 
On  one  occasion  after  joining  the  army  he  spoke  for 
one  and  a  half  hours  on  the  duties  of  a  Christian 
soldier.  He  was  always  talking  to  his  comrades,  and 
nothing  pleased  him  better  than  discussion  or  argu- 
ment. Over  and  over  again  he  had  been  told  to  shut 
up,  hold  his  jaw.  Now,  after  receiving  the  kick  he 
went  to  his  medical  officer  literally  holding  his  jaw, 
and  after  the  wound  had  been  stitched  was  sent  back 
to  his  tent.  He  felt  inclined  to  remonstrate  (to  jaw), 
but  thought  it  better  to  hold  his  jaw.  Later  in  the 
afternoon  the  pain  was  so  bad  in  the  jaw  that  he  was 
visited  by  the  doctor  and  sent  into  hospital.  The 
next  evening,  however,  he  found  himself  taking  part 
in  a  sing-song — an  inconsistency  to  which  the  un- 
conscious promptly  replied  by  "holding  his  jaw" 
figuratively. 

THE   MATERIALISATION   OF  WORDS. 

It  must  be  remembered  that  we  are  here  dealing 
with  what  is  archaic  and  crude  in  the  unconscious, 


PSYCHOLOGICAL  MECHANISMS  65 

with  what  links  us,  the  heirs  of  all  the  ages,  mentally 
with  primitive  man.  In  this  lower  culture  there  is 
no  clear  distinction  between  words  and  the  objects 
they  denote. 

Sir  J.  G.  Frazer 6  writes: — "  Unable  to  discriminate 
clearly  between  words  and  things,  the  savage  com- 
monly fancies  that  the  link  between  a  name  and 
the  person  or  thing  denominated  by  it,  is  not  a  mere 
arbitrary  and  ideal  association,  but  a  real  and  sub- 
stantial bond  which  unites  the  two." 

The  utterance  of  the  correct  word,  the  power  of 
the  word,  has  a  magical  effect ;  the  "  Open  Sesame  " 
and  "  Rumpelstiltskin  "  of  the  fairy  stories  have  been 
believed  and  carried  out  in  our  childhood's  play.  A 
Central  Australian  has  but  to  get  the  magician  doctor 
to  pronounce  a  curse  on  his  enemy:  "May  your 
heart  be  rent  asunder ;  may  your  backbone  be  split " 
— and  the  enemy's  backbone  is  split  unless  he  get  on 
his  side  a  more  powerful  magician  to  ward  off  the 
words. 

"  When  the  Sulka  of  New  Britain  are  near  the  terri- 
tory of  their  enemies  the  Gaktei,  they  take  care  not 
to  mention  them  by  their  proper  name,  believing  that 
were  they  to  do  so,  their  foes  would  attack  and  slay 
them.  Hence  in  those  circumstances  they  speak  of 
the  Gaktei  as  o  lapsiek,  that  is,  the  '  rotten  tree  trunks,' 
and  they  imagine  that  by  calling  them  that  they  make 
the  limbs  of  their  dreaded  enemies  ponderous  and 
clumsy  like  logs.  This  example  illustrates  the 
extremely  materialistic  view  which  these  savages 
take  of  the  nature  of  words  ;  they  suppose  that  the 
mere  utterance  of  an  expression  signifying  clumsi- 
ness will  homceopathically  affect  with  clumsiness 
the  limbs  of  their  distant  foemen." — Frazer,  ibid, 

P.  331. 

6  ' '  The  Golden  Bough, ' '  Vol.  III.    "  Taboo  and  the  Perils  of 
the  Soul."    3rd  Edition,  p.  331. 


66  WAR-SHOCK 

A   SPEECH-COMPLEX.7 

The  mutism  can,  in  this  patient  (No.  43)  be  traced  to 
early  difficulty  in  his  speech,  for  he  began  to  speak 
late — not  till  after  five — and  he  could  not  speak 
properly  until  he  was  ten  years  old. 

I  have  pointed  out  elsewhere 8  that  it  is  from  the 
mother  that  the  child  gets  his  first  encouragement  to 
speak  and  that  later  on,  in  certain  cases,  resistance  may 
arise  against  anything  learned  from  the  mother — 
against  speaking  altogether.  There  was  in  this  case 
much  opposition  between  him  and  his  mother  ;  on 
account  of  this  he  was  brought  up  to  a  large  extent 
by  other  relations.  After  the  birth  of  a  brother, 
when  he  was  returning  to  his  own  home,  he  told  his 
mother  that  she  was  not  his  mother  at  all  now  that 
she  had  another  child.  Although  he  had  never  been 
dumb  till  the  accident  on  December  31st,  1914,  when 
annoyed  at  home  or  in  the  workshop  he  would  take 
refuge  in  silence,  sometimes  not  speaking  to  anyone 
for  several  hours.  After  the  accident  the  subsequent 
attacks  of  mutism  (four  in  two  weeks)  occurred  after 
some  excitement,  such  as  winning  at  cards,  attending 
church.  There  was  a  great  deal  in  his  history  show- 
ing conflict  between  himself  and  his  parents,  a  number 
of  things  which  wounded  the  too  sensitive  disposition 
of  the  child.  He  took  religion  seriously  (Wesley an) 
at  the  age  of  11,  his  parents  being  non-religious 
Church  of  England  people.  Without  going  into  great 
detail  the  evidence  may  be  summed  up  as  showing 
strong  conflict,  conscious  and  unconscious,  between 
son  and  mother  in  a  person  of  sensitive  predisposition. 

Though  he  remained  free  for  some  time  after 
his  last  attack,  which  was  immediately  stopped  by 

7  A  complex   is   a  system    of   ideas,    dynamically   active 
emotionally  charged  from  an  unconscious  source. 

8  Stammering  as  a  Psycho-Neurosis,  17th  International  Con- 
gress of  Medicine,  1913.    Section  on  Psychiatry. 


PSYCHOLOGICAL  MECHANISMS  67 

suggestion  (without  hypnotism),  it  is  doubtful  whether 
the  same  or  other  symptoms  will  not  recur. 

PSYCHOLOGICAL    COMPENSATION. 

This  patient  illustrates  the  mechanism  which  Jung 
terms  psychological  compensation/  and  which  Dr.  Gee 
noted  in  the  above  quoted  aphorism.  This  young  man 
compensates  for  his  verbosity  by  recurrent  attacks  of 
mutism;  a  phenomenon  which,  in  a  milder  degree,  had 
often  been  present.  Thus,  after  an  evening's  heated 
talk  (in  his  pre-soldier  days),  he  had  frequently  lapsed 
into  sudden  and  absolute  silence,  recalling  Sydney 
Smith's  discovery  of  Macaulay's  brilliant  flashes  of 
silence,  when  he  would  resent  any  attempt  at  getting 
into  conversation  with  him. 

In  another  patient  (No.  13)  the  paraplegia,  which 
followed  a  mild  degree  of  frost-bite,  was  an  unconscious 
compensation  for  having  been,  in  his  opinion,  over- 
worked at  trench-digging  and  road-making. 

Compensation  has  a  wide  scope  in  mental  life.  For 
example,  persons  who  are  pedantically  accurate  in  their 
choice  of  words,  dealing  sledge-hammer  blows  at 
any,  even  the  slightest  departure,  from  meticulous 
verbal  accuracy,  have  not  infrequently  been  found 
to  be  grossly  careless  as  to  their  facts,  or  distorting 
the  facts  and  juggling  with  quotations  to  meet  their 
own  ends.  Not  only  the  Puritans 

"  Compound  for  sins  they  are  inclined  to 
By  damning  those  they  have  no  mind  to." 

COMPROMISE   FORMATION   IN  HYSTERIA. 

The  hysterical  manifestation  is,  according  to  Freud, 
a  compromise  between  a  repressed  wish  and  an  inhibi- 
tion ;  the  result  of  a  mental  conflict  between  the  ego 

9  "Collected  Papers  on  Analytical  Psychology,"  by  C.  G- 
Jung.  Translation  edited  by  Dr.  Constance  E.  Long.  London 
Bailliere,  Tindall  &  Cox,  1916.  P.  280. 


68  WAR-SHOCK 

and  the  gregarious  instinct  —  termed  by  Mr.  W. 
Trotter1  the  "herd  instinct."  A  good  instance  of 
this  compromise  is  furnished  by 

No.  54,  a  young  Australian  private,  aged  19, 
suffering  from  what  Captain  A.  D.  Griffith 2  has  termed 
"  War-amblyopia.*' 

He  was  admitted  for  loss  of  sight  in  the  right  eye, 
with  normal  vision  in  the  left.  There  was  a  right 
ptosis  present  from  childhood.  He  had  been  seen 
by  Colonel  Purves  Stewart  and  by  the  eye  specialists, 
Captain  M.  M.  Townshend  and  Captain  Griffith.  In 
the  right  eye  on  January  /th  there  was  perception 
of  light  and  nothing  more  ;  the  defect  had  begun  on 
November  1 5th.  This  is  the  history  he  gave  me  : 
On  November  15th  he  was  sniping  through  a  loop- 
hole when  an  enemy  bullet  knocked  a  piece  off  the 
stock  of  his  rifle.  He  continued  at  his  post;  five 
shots  later  another  bullet  struck  the  sand  around  the 
loophole.  The  right  eye  began  to  water.  He  shut 
the  loophole  and  went  away  for  an  hour.  He  then 
returned,  the  eye  being  better,  opened  the  loophole, 
posed  his  rifle,  and  then  found  he  could  not  see  the 
sights  on  the  rifle.  There  was  obviously  nothing  to 
do  but  go  to  the  doctor.  The  vision  got  rapidly 
worse,  and  in  a  few  hours  he  had  lost  perception  of 
light.  Let  me  add  that  he  was  a  lad  of  great,  almost 
reckless,  courage  and  of  great  independence  of  spirit. 

This  Australian  is  a  type  with  the  gregarious  instinct 
highly  developed — his  soldier's  quality  is  strong.  A 
bullet  hits  the  stock  of  his  rifle  whilst  sniping — 
the  enemy  have  located  him.  It  must  be  remem- 
bered that  he  is  sniping,  so  that  to  go  away  would 
have  been  quite  allowable.  But  he  does  not  give  up. 
Then  another  bullet  comes  along.  The  unconscious, 
acting  on  behalf  of  the  ego  instinct,  sets  the  eye 

1  The  Herd  Instinct  in  War  and  Peace. 

2  The  Lancet,  June  24th.  1916,  p.    124-6 


PSYCHOLOGICAL  MECHANISMS  69 

awatering,  forcing  him  to  relinquish  his  post.  Then 
the  soldier's  instinct  asserts  itself,  the  eye  ceases  to 
water,  and  he  returns  to  the  loophole.  But  here  the 
egocentric  instinct,  self-preservation,  reasserts  itself, 
and  the  unconscious  adopts  a  stronger  attack.  He  is 
stricken  blind  in  the  shooting  eye  (note,  also,  that  it 
is  the  seat  of  a  congenital  deformity).  He  is  now 
unable  to  carry  out  his  conception  of  the  soldier's 
duty,  and  without  loss  of  self-respect  is  able  to  retire, 
his  safety  guaranteed.  Shall  we  say  that  the  com- 
promise ends  with  the  odd  trick  in  favour  of  the 
egocentric  instinct  ?  Even  so,  it  will  be  granted 
from  the  measure  adopted  by  the  unconscious  that 
he  must  have  been  a  first-class  fighting  man.  Blind- 
ness has  always  been  regarded  as  one  of  the  direst 
calamities  that  could  happen  to  youth,  and  for  some 
weeks  he  had  believed  that  his  right  eyesight  was 
gone. 

DUMBNESS    TO    DODGE    THOUGHT. 

Another  instance  of  mutism  originally  due  to  con- 
flict is  that  of  case  39,  described  on  page  29. 
Just  before  the  shell  explosion  which  threw  him  into 
the  air  and  rendered  him  unconscious,  his  mate,  with 
whom  he  had  just  been  talking,  a  man  he  knew  in 
England — the  two  had  enlisted  together — was  killed 
immediately  in  front  of  him.  It  was  an  explosion 
not  dissimilar  to  the  one  he  had  been  through  in  a 
pit  in  England  eight  years  before,  when  his  brother 
(seven  years  older  than  himself)  was  killed  in  a  pit 
explosion,  the  patient  escaping  but  remaining  quite 
dumb  for  15  months.  Investigation  showed  some 
rivalry  between  the  brothers  that  had  continued  from 
childhood,  side  by  side  with  much  brotherly  affection 
and  interest  in  each  other.  He  had  often  wished 
that  he  had  no  brother  or  that  he  would  go  away,  or 
he  would  weave  phantasies  of  what  might  happen 
were  his  brother  very  ill  or  dead. 


70  WAR-SHOCK 

The  death  of  his  brother  and  his  own  escape  seemed 
to  him  as  if  he  had  been  making  his  thoughts  real,  a 
conception  as  Frazer  has  shown  common  in  primitive 
man.  His  guilty  conscience  will  prevent  any  such 
wicked  thoughts  arising  anew  by  taking  away  speech 
altogether.  He  remained  dumb  for  15  months; 
time  did  not  permit  any  full  investigation  so  that  it  is 
impossible  to  say  what  eventually  brought  about 
recovery.  The  circumstances  under  which  the 
mutism  recurred  are  of  the  same  type  as  the  earlier 
instance.  The  friend  who  was  killed  almost  by  his 
side  repeats  the  history  of  the  brother's  death ;  there 
is  a  revival  of  the  feelings  which  had  never  been  dis- 
posed of  in  consciousness,  and  therewith  the  primi- 
tive belief  that  if  ideas  are  not  expressed  in  words 
they  have  not  really  been  in  the  mind ;  the  dumb- 
ness was  here  an  endeavour  to  dodge  thoughts  which 
came  up  unbidden  and  whose  origin  remained,  of 
course,  unknown  to  the  patient — even  after  recovery. 
Another  primitive  idea  lay  at  the  back  of  the  resist- 
ance to  treatment ;  the  feeling  that  the  affliction  was 
a  punishment  sent  by  God  to  be  removed  in  God's  good 
time,  when  the  sinner  was  fully  repentant. 

DEAF  MUTISM  AS  A  WISH-FULFILMENT. 

Mutism  can  have  other  causes  ;  No.  36  was  in  the 
trenches  with  a  mate  with  whom  he  had  enlisted  in 
Australia;  this  friend  of  many  years  standing  was 
killed  by  a  machine-gun  fired  a  yard  in  front  of  him. 
He  lost  his  head  that  day  and  felt  unbalanced.  He  felt 
he  must  get  outside  the  trenches  and  climbed  on  to  the 
parapet,  whence  he  was  pulled  back  by  the  sergeant 
several  times.  Two  days  later,  after  a  shell  explosion  a 
yard  away,  by  which  he  was  partially  buried,  he  lost 
consciousness.  He  recovered  some  days  later  to  find 
himself  on  board  ship ;  he  could  neither  speak  nor 
hear  and  could  hardly  stand  on  his  legs. 


PSYCHOLOGICAL  MECHANISMS  71 

Under  hypnosis  he  could  recall  whispering  a  few 
words  as  he  was  being  carried  on  board  and  had 
then  again  relapsed  into  unconsciousness. 

The  wish  for  death  can  be  gathered  from  this 
history  ;  the  attempt  to  climb  on  to  the  parapet 
which  was  described  by  himself  as  suicidal ;  the 
relapse  into  loss  of  consciousness  (taking  the  original 
loss  of  consciousness  as  due  to  commotio  cerebri)\ 
the  inability  to  stand ;  the  deaf  mutism  which  outlasts 
the  other  symptoms  as  the  wish  for  death  weakens, 
death  which  severs  communication  between  man  and 
his  fellows  and  is  well  symbolised  by  deafness  and 
speechlessness.  Sometimes  (No.  35)  mutism  by 
itself  is  the  symbol  of  this  wish  for  death,  to  have 
done  with  the  horrors  of  the  battlefield.  It  will  be 
gathered  that  this  is  quite  consistent  with  bravery  in 
the  battlefield  or  in  the  trenches,  each  representing 
partial  elements  in  the  man's  mental  make-up. 

Of  course,  if  any  investigator  were  stupid  enough 
to  ask  such  patients  did  they  want  to  die,  they  would 
properly  answer  no ;  they  might  even  say  they  had 
never  thought  of  it,  although  closer  investigation  will 
not  infrequently  show  such  a  thought  had  been  present, 
though  perhaps  but  fleetingly.  Clearly  the  wish  for 
death  is  incomplete ;  they  do  not  die,  they  only  more 
or  less  simulate  death. 

PARAPLEGIA  AS  A  WISH-FULFILMENT. 

In  No.  10  the  paraplegia  was  a  wish-fulfilment- 
This  patient  was  invalided  to  Malta  for  mild  frost- 
bite in  the  toes  of  the  left  foot.  During  this  treat- 
ment he  suddenly  lost  power  in  the  left  lower  limb ; 
on  being  transferred  to  an  infectious  diseases  hospital 
(for  scabies)  he  lost  power  of  the  right  lower  limb. 
On  examination  seven  weeks  later  there  was  a  stocking 
analgesia  of  both  lower  limbs,  which  were  somewhat 
rigid.  There  was  a  rapid  clonic  tremor  of  the  anterior 


72  WAR-SHOCK 

thigh  muscles.  All  the  limbs  could  be  moved 
moderately  as  he  lay  in  bed.  Gait  feeble  and 
shuffling,  using  two  sticks  and  almost  bent  double. 
Knee  jerks  exaggerated,  with  tendency  to  right  ankle 
clonus.  Plantar  reflexes  absent  at  toes.  All  muscles 
reacted  normally  to  faradism. 

On  December  31st  the  patient  was  dressed,  wait- 
ing in  the  hospital  grounds  for  embarkation  to  England, 
as  a  cot  case,  the  left  leg  being  useless.  He  had 
reported  the  scabies  that  morning.  Then  the  order 
for  embarkation  was  cancelled ;  he  was  carried  back 
to  the  ward  and  transferred  by  ambulance  the  next 
morning  as  a  "  walking  case  "  to  the  infectious  diseases 
hospital.  He  was  able  to  hop  into  the  ambulance, 
but  at  the  other  end,  some  twenty  minutes'  drive,  he 
was  unable  to  walk,  the  right  leg  had  lost  all  power 
in  the  interval.3  He  thought  he  was  not  receiving 
proper  attention,  and  wanted  to  show  that  he  really 
was  ill.  Hence  the  paraplegia.  It  was  not  malinger- 
ing ;  the  analgesia  and  the  alteration  in  the  reflexes 
showed  this,  as  did  the  patient's  gallant  attempts  to 
walk.  Under  hypnosis,  although  complete  move- 
ments of  the  legs  were  obtained,  walking  could  not 
be  suggested ;  after  the  second  seance,  when  he  had 
managed  a  couple  of  steps  unsupported,  he  had  an 
attack  of  "  grande  hysteric."  It  was  under  hypnosis 
that  he  expressed  the  thought  that  it  was  unfair  to 
send  him  as  a  walking  case  when  the  day  before  he 
was  a  "  cot " — and  his  leg  was  no  better. 

Hypnotism  was  given  up,  as  the  patient  was 
not  making  any  improvement;  instead  I  made  an 
appeal  to  him,  rousing  an  emotion  that  ended  in  a 

3  It  was  of  course  quite  in  order  that  he  should  go  to 
England  as  a  cot  case — this  meant  he  would  be  carried  from 
the  ambulance  on  to  the  lighter  and  thence  to  the  hospital 
ship.  And  of  course  he  was  quite  suitable  as  a  walking  case 
for  transfer  from  one  hospital  to  another. 


PSYCHOLOGICAL  MECHANISMS  73 

flood  of  tears.  He  lay  awake  all  that  night  making 
up  his  mind  that  he  would  walk,  and  the  next  day  the 
sticks  were  relinquished ;  he  was  cured  of  the  para- 
plegia. The  analgesia  had  been  progressively  dis- 
appearing in  the  way  typical  of  hysteria.  The 
reflexes  became  normal.  The  recovery  was  helped 
here  by  the  presence  of  another  paraplegic  (hysterical) 
No.  12,  who  had  been  subsequently  admitted  to  an 
adjoining  ward  and  had  made  a  quick  recovery. 

THE  CEDIPUS  MYTH. 

Freud  took  the  CEdipus  myth  as  the  type  of  the 
infantile  relationship  to  the  parents.  CEdipus  is  the 
archetype  of  the  son's  unconscious  incestuous  love  for 
a  mother  and  rivalry  with  a  father.  I  am  inclined  to 
regard  this  relationship  in  a  rather  different  light. 
Though  in  the  phantasies  or  dreams  of  the  adult  one 
gets  evidence  of  this  love  towards  the  mother  and 
rivalry  towards  the  father,  this  is  rather  to  be  viewed 
as  symbolic  of  a  desire  to  return  to  the  infantile 
dependence  upon  the  mother  and  the  undisputed  claim 
to  her  whole  care  and  tenderness,  the  rivalry  towards 
the  father  symbolising  the  resentment  at  the  inter- 
ference with  this  relationship.  The  deaf  mute, 
described  on  p.  69,  is  a  typical  instance,  where 
the  brother  simply  stands  as  the  surrogate  of  the 
father. 

The  following  case  of  loss  of  memory  is  an  example 
of  this  infantile  relationship  to  the  mother. 

No.  79  had  been  suffering  from  complete  loss  of 
memory  for  six  weeks.  When  admitted  he  had  a 
vacant  blank  look,  he  did  not  know  his  name,  and  could 
only  answer  "  yes  "  and  "no."  His  memory  recovered 
completely.  The  interest  centres  in  the  memories 
that  immediately  preceded  the  amnesia.  He  was 
only  1 7  when  he  was  in  Gallipoli ;  he  was  invalided, 
and  it  was  whilst  convalescent  in  Malta  that  the 


74  WAR-SHOCK 

attack  came  on,  when  he  was  visiting  some  friends 
just  at  Christmas  time.  Mrs.  X.,  a  motherly,  kindly 
woman,  was  baking  some  cakes.  His  thoughts 
travelled  back  to  his  people's  home  at  Christmas,  to 
his  mother.  Then  he  saw  himself,  a  child  of  five, 
making  cakes  in  the  kitchen  alongside  his  mother. 
He  saw  himself  putting  one  of  the  cakes  on  paper  in 
the  oven.  The  cake  was  burnt,  but  "  I  ate  it  myself 
all  right,  taking  some  strawberry  jam  out  of  the  pot 
for  the  cake."  A  little  later  he  was  very  dizzy,  with 
a  terrible  headache ;  a  friend  took  him  back  to  camp, 
where  it  was  at  first  thought  he  was  drunk.  But  the 
medical  officer  who  was  sent  for  of  course  recognised 
his  condition.  He  offered  a  piece  of  cake  (from  his 
store)  to  the  doctor  the  next  morning,  although  with- 
out being  able  to  give  any  explanation.  This  amnesia 
was  clearly  an  attempt  to  blot  out  all  the  surrounding 
associations  with  the  war,  to  keep  this  lad  back  amid 
the  happy  experiences  of  childhood.  These  and 
many  other  scenes  which  were  reproduced  in  hypnosis 
were  immediately  told  him  on  awaking ;  and  very 
soon  memory  returned  for  the  whole  period.  There 
were  other  events,  unsuitable  to  repeat  here, 
which  showed  that  certain  other  responsibilities 
had  been  placed  upon  him  which  were  too  much 
for  his  age. 

But  that  under  sufficient  stress  of  circumstances 
there  can  be  at  any  age  a  return  to  this  infantile 
adaptation  may  be  read  in  the  following  sketch: — 

A  sergeant  (No.  26),  34  years  of  age,  had  been 
1 6  years  in  the  army;  he  was  wounded  in  the  left 
frontal  region  by  shrapnel.  He  was  unconscious  for  12 
hours.  About  two  weeks  after  the  wound  had  healed 
he  lost  power  in  the  right  hand.  When  he  came  under 
observation,  six  weeks  later,  there  was  subjective 
and  objective  feeling  of  cold  in  the  right  hand  (he 
wore  a  glove),  and  a  '*  tingling  feeling  as  of  a  mild 


PSYCHOLOGICAL  MECHANISMS  75 

electric  current "  ;  analgesia-anaesthesia  to  3  in.  above 
wrist ;  loss  of  power  in  hand  ;  grasp  feeble ;  could 
not  fully  flex  fingers  ;  was  unable  to  hold  things  in 
the  hand  ;  could  not  write  with  this  hand.  He  was 
to  some  extent  ambidextrous  by  training.  He 
batted  and  shaved  with  either  hand  but  was  a  left- 
hand  bowler  and  a  right-hand  writer. 

With  suggestion  under  hypnosis  all  abnormal  sen- 
sation disappeared  and  normal  sensation  returned; 
the  hand  recovered  its  power.  He  gave  a  rather 
interesting  exhibition  of  rationalisation.*  One  day, 
under  hypnosis,  I  told  him  to  write  home  to  his 
mother.  He  was  unable  to  carry  out  the  suggestion 
post-hypnotically,  telling  me  he  had  tried  to  write 
but  his  hand  was  too  tired.  I  then  told  him  (again 
under  hypnosis)  to  write  me  a  letter.  The  next  day 
he  handed  me  a  well-written  letter.  I  thanked  him 
and  said,  ' '  But  why  did  you  write  me  since  I  see  you 
every  day  ?  "  He  replied,  "  I  thought  it  would  be 
nice  to  show  you  how  I  am  getting  on."  He 
was  quite  unaware  of  my  suggestion  and  con- 
sciously he  did  not  know  whence  came  the  impulse 
to  write.  As  is  so  frequently  the  case,  consciousness 
proceeds  to  find  a  rational  motive,  a  mental  process 
which  should  put  us  on  our  guard  not  only  in  our 
dealings  with  others.  The  advice  given  by  Lord 
Mansfield  to  a  newly  -  appointed  judge  will  be 
remembered  :  "  Give  your  verdict,  it  is  pretty  sure 
to  be  right;  never  adduce  your  reasons — they  are 
equally  sure  to  be  wrong." 

The  paresis  in  the  right  hand  had  occurred  suddenly 
one  day  just  as  he  was  about  to  write  a  letter  to  his 
mother.  "  I  could  not  hold  the  pen  ;  there  was 
such  a  tired  feeling  in  my  hand."  (This  persisted 
until  treated.)  He  was  about  to  write  to  his  mother 

4  See  Ernest  Jones :    Rationalisation    in    Every-Day  Life. 
Papers  on  Psycho- Analysis.   London  :  Bailliere,  Tindall  &  Cox. 


76  WAR-SHOCK 

that  he  thought  she  need  not  be  worried  about  the 
condition  of  a  younger  brother  who  had  become  a 
wreck  after  a  bomb  explosion  at  Y.  The  brother 
would  get  better  in  time.  He  was  not  going  to 
mention  his  own  injury  as  he  did  not  want  to  worry 
her.  Under  hypnosis  he  admitted  that  he  would 
have  very  much  liked  her  to  know  about  his  accident, 
he  greatly  wanted  her  love  and  sympathy. 

Altruism,  the  wish  not  to  give  additional  distress  to  his 
mother,  is  here  in  conflict  with  the  egocentric  impulse. 
Here  again  the  hysterical  symptom  arises  from  a  com- 
promise between  two  opposed  affective  impulses 
just  as  we  saw  in  the  case  of  the  Australian  sniper, 
described  on  page  67.  Paresis  of  the  hand  prevents 
the  gratification  of  either  impulse,  but  with  the  balance 
in  favour  of  the  more  primitive  instinct,  since  his 
illness  is  now  more  severe,  and  his  mother  must  be 
written  to  by  a  third  person  who  tells  her  of  her  son's 
condition.  But  he  does  not  write  about  it  himself. 

The  history  of  this  soldier  of  16  years'  service  all 
over  the  world  shows  how  powerful  was  the  maternal 
allegiance.  He  had  never  been  interested  in  any 
woman,  had  never  been  engaged  or  even  condescended 
to  kiss  one,  not  even  to  hold  a  strange  woman's  hand 
"  so  very  little  longer."  He  had  once  won  a  few 
hundred  pounds  in  a  lottery  and  had  sent  it  home  to 
his  mother.  I  said  to  him,  "  I  suppose  after  the  war 
you'll  marry."  "  Not  while  there's  mother  to  look 
after."  His  father,  I  should  add,  was  alive,  and 
they  were  not  in  bad  circumstances.  This  history  is 
sufficient  to  understand  the  origin  of  the  paresis ;  any 
deeper  analysis  of  the  hysteria  is  not  my  purpose 
here.  But  I  would  point  out  that  this  is  another  case 
in  illustration  of  the  thesis  that  hysteric  must  not  be 
read  as  degenerate.  This  patient  is  neurotic,  but 
he  is  a  fine  soldier,  who  had  served  in  the  South 
African  War,  where  he  had  been  slightly  wounded ; 


PSYCHOLOGICAL  MECHANISMS  77 

a  shell  explosion  had  blown  him  up  whilst  in 
France,  for  which  he  was  invalided  for  four  months, 
and  he  then  went  to  the  Dardanelles.  He  is  an 
N.C.O.  of  charming  manners,  of  good  intelligence, 
and  a  "neurotic." 


CHAPTER  IV 

ANXIETY-HYSTERIA 

WHILST  in  conversion-hysteria  the  most  prominent 
clinical  symptom  is  somatic,  in  anxiety-hysteria  the 
most  prominent  symptoms  are  mental.  A  feeling  of 
anxiety,  dread  without  adequate  cause,  a  nameless 
terror  or  some  phobia,  intense  exhaustion  after  the 
most  trivial  mental  or  physical  effort,  distinguish 
this  class  of  case;  sleeplessness  and  headache  are 
common,  whilst  sensory  motor  disturbances,  though 
frequently  present  in  the  form  of  some  analgesic  area, 
may  be  absent. 

The  phobias  and  obsessions  are  of  the  most  varied 
kind ;  Withermann l  says  the  desire  for  the  Iron  Cross 
is  often  of  an  obsessional  nature.  Steiner2  cites  the 
Case  of  an  N.C.O.,  a  congenital  psychopath,  who 
would  not  let  his  company  fire  upon  the  enemy  in 
consequence  of  the  "obsession"  that  the  enemy  men 
had  women  and  children  dependent  upon  them.  He 
was  affected  by  a  constant  taste  of  blood  and  a  smell 
of  corpses.  Binswanger 3  mentions  a  similar  case  of 
"obsession"  where  the  following  dream  dialogues 
were  overheard:  "Do  you  see  the  Englishman 
there?"  "  Has  he  got  parents?  "  "  Has  he  a  wife?  " 
"  I  won't  shoot  him  dead — " 

1  Withermann  quoted  in  Zeitschrif t  fur  die  gesamte  Neuro- 
logie  und  Psychiatric.    Band  12.    Heft.  4.    March,  1916. 

2  Ibid,  p.  30.     H.  2/3.     1915. 

3  Hysterosomatische     Krankheitserscheinungen    bei     der 
Kriegshysterie.    Monat.  f.  Psych,  u  Neurol.  38.     Heft.  1/2. 

1915. 

78 


ANXIETY-HYSTERIA  79 

Vaso-motor  disturbances  invariably  accompany  the 
feeling  of  "anxious  dread,"  which  is  perhaps  the  best 
term  one  can  find.  These  vaso-motor  symptoms  are 
many  and  various;  all  the  physiological  systems 
may  be  disturbed,  though  not  all  may  be  affected  at 
any  one  time.  The  commonest  of  these  disturbances 
are: — 

a.  CIRCULATORY. — Already  described  on  page42 

under  the  "Soldier's  Heart ;"  congestion  of 
the  extremities  aping  Raynaud's  disease. 

b.  RESPIRATORY. — Feeling  of  suff ocation,breath- 

lessness,  air  hunger,  dyspnoea,  hay  fever, 
asthmatic  conditions. 

c.  INTESTINAL. — Anorexia,    vomiting,    indiges- 

tion— colic — diarrhoea — (constipation  more 
rarely). 

d.  EXCRETORY. — A  sweating,  especially  of  the 

palms,  urticaria — transient  cedemas — polla- 
kuria,  colicky  pains  over  the  bladder. 

e.  NERVOUS  SYSTEM. — Headache,  parsesthesias, 

photophobia,    hyperacusis,    disturbances   in 
the  sense  of  smell  and  taste. 
/.  MUSCULAR  SYSTEM. — Tremors,  generally  fine 

and  often  confined  to  the  hands. 
The  thyroid  is  not  frequently  enlarged,  some- 
times   with    slight    exophthalmos ;     more 
rarely  the  ocular  symptoms  seen  in  Grave's 
disease  are  found. 

The  blood  count  may  show  a  total  increase  of  the 
white  cells  with  a  lymphocytosis. 
v&The  following  is  a  fairly  typical  example  of  this 
kind ;  it  is  a  case  of 

REPRESSION   OF  FEAR. 

No.  84.  The  patient,  aged  25,  who  had  gone 
through  the  Gallipoli  campaign  without  a  scratch  and, 
as  he  said,  with  practically  no  fears  was  later  frost- 


80  t  WAR-SHOCK 

bitten  in  Salonica.  He  was  sent  to  hospital  on 
December  18th.  When  he  came  under  me  on 
February  7th  the  finger  of  the  right  hand  was  well,  but 
there  was  some  loss  of  grip.  He  was  then  suffering 
from  insomnia,  terrifying  dreams,  and  tremors  of  the 

hands.  On  December  6th  at  K ,  when  holding 

horses  on  a  flying  bridge  the  animals  started  and 
he  was  thrown  into  the  water ;  he  was  picked  out  none 
the  worse.  The  next  day  it  happened  that  his  horse 
was  shot  under  him,  but  he  escaped.  A  few  days  later 
the  middle  ringer  got  frost-bitten,  and  he  was  sent  to 
hospital,  where  his  hands  began  trembling,  sleepless- 
ness came  on  and  severe  headaches. 

The  patient  was  a  thick-set  sturdy  fellow,  jovial  and 
kindly,  the  son  of  an  agricultural  labourer.  The 
thyroid  was  diffusely  enlarged,  but  there  were  no 
ocular  signs  of  Graves's  disease  and  no  signs  of 
disease  in  the  central  nervous  system,  other  than  the 
tremors.  The  blood  pressure  was  high.  There  was 
a  fine  tremor  of  the  hands,  six  to  the  second.  The 
pulse  was  irregular  and  rapid,  and  there  were  not 
infrequent  attacks  of  cardiac  palpitation  —  almost 
anginal  in  character. 

Blood  examination.4 

Total  white  cells,  11,500  per  cmm. 
Neutrophile  polymorphs,  48  per  cent. 
Lymphocytes,  small,  47        ,, 

Lymphocytes,  large,  3        „ 

Large  mononuclears,  2        „ 

The  extremities  were  cold  and  blue  (only  one 
finger  on  one  hand  had  been  frost-bitten),  he  sweated 
violently  in  the  palms,  there  was  hyper-sensitiveness 
to  sound,  occasional  attacks  of  dizziness  and  a  feeling 
of  suffocation,  making  him  gasp  for  breath.  There 
was  frequent  desire  to  micturate. 

4  I  am  indebted  to  Major  Arkwright,  R.A.M.C.,  M.O.  i/c 
of  the  Pathological  Laboratory,  for  the  examination  of  the 
blood  in  this  and  the  other  cases. 


ANXIETY-HYSTERIA  81 

This  is  very  much  like  the  description  of  a  severe 
state  of  fright,  such  as  many  have  experienced  in  the 
Examination  Hall,  when  the  hands  get  a  little 
tremulous  and  the  palms  sweaty  ;  and,  as  we  know, 
these  dreadful  infernos  are  provided  by  some  thought- 
ful architects  with  extra  latrine  accommodation. 

His  terrifying  dream  was  always  the  same.  "  I  see 
a  Frenchman  digging  a  knife  into  a  horse.  He  gets 
off  his  cart  to  do  this.  It  is  in  Serbia."  Not  only 
at  night  but  during  the  day  this  comes  up  as  a  vision. 
It  is  an  actual  occurrence.  He  saw  a  French  trans- 
port soldier,  drunk,  get  off  the  waggon  and  plunge  a 
knife  into  a  mule  to  make  it  go.  With  some  others 
he  stopped  the  Frenchman  and  drove  the  waggon  into 
quarters.  (Note,  the  mule  becomes  a  horse  in  the 
dream.)  The  patient's  feelings  about  horses  were 
very  intense.  He  had  been  used  to  horses  since 
childhood;  his  earliest  recollections  are  of  driving 
with  his  father  or  of  being  put  up  on  the  plough- 
horse.  As  a  boy  he  was  engaged  about  the  stables 
and  later  became  a  groom.  He  wept  profusely  when 
talking  to  .me  of  the  sufferings  experienced  by  the 
wounded  mules  in  Gallipoli,  and  when  I  suggested 
that  human  beings  suffered  more  he  would  not  have 
it  so.  Animals  could  not  talk.  No  animals  should 
have  been  allowed  there,  he  said.  He  never  had  any 
trouble  with  horses,  for  he  understood  them  exactly, 
and  he  was  always  given  the  difficult  ones  to  manage. 
In  short,  he  was  as  doting  on  horses  as  any  maiden 
lady  over  her  Fido. 

We  suspect  all  exaggerated  sentiments ;  with  Queen 
Gertrude  we  feel  "The  lady  doth  protest  too  much." 
Investigation  soon  showed  that  the  suspicion  was 
justified.  He  identified  himself  with  the  horse.  He 
was  the  horse  of  the  dream ;  it  is  he  who  ought  not 
to  have  been  in  Gallipoli — it  is  too  much  for  him  and 
others.  Consciously  the  soldier  instinct  in  my  patient 


82  WAR-SHOCK 

would  know  no  fear  for  himself.  But  as  the  Latin 
satirist  says  : — 

"  Primus  in  orbe  decs  fecit  timor." 

Fear  is  a  primary,  natural  instinct,  and,  like  murder, 
will  out.  So  long  as  the  patient  was  actively  engaged 
looking  after  the  horses  he  could  expend  all  his 
mental  excitement  in  pity  for  them — i.e.,  himself. 
But  condemned  to  inactivity  by  the  frost-bitten  finger 
this  mental  excitement  (which  even  before  had  been 
abnormally  expressed)  finds  no  outlet,  emotionally  or 
actually.  Could  it  have  reached  consciousness  the 
patient  would  have  been  able  to  deal  with  it,  as  he 
subsequently  did  with  our  help.  Such  cases  are  often 
due  to  fear — not  necessarily  fear  of  shrapnel — thus 
bottled  up,  or  repressed  from  consciousness.  This  fear 
not  being  acknowledged  or  worked  off  becomes  morbid 
fear,  morbid  because  it  is  no  longer  objective. 

That  the  person  should  become  a  horse  in  the 
unconscious  will  not  startle  anyone  who  has  dipped 
ever  so  little  into  the  totems  and  taboos  of  the  lower 
races.  The  kangaroo  tribe,  for  instance,  as  Sir  J.  G. 
Frazer5  shows,  consists  of  kangaroos  and  kangaroo 
men,  who  actually  are  kangaroos  and  delight  to  show 
their  identity  by  identity  of  action.  But,  indeed,  it  is 
not  necessary  to  travel  to  Australia.  Which  of  us  has 
not  galloped  as  a  horse,  pawed  the  air,  impatiently 
neighed,  and  chafed  at  the  bit.  And  when  some  day 
our  child  comes  galloping  into  the  room,  kicks  over  a 

5  "  In  the  Alcheringa  lived  ancestors,  who  in  the  native  mind 
are  so  intimately  associated  with  the  animals  or  plants,  the 
names  of  which  they  bear,  that  an  Alcheringa  man  of,  say,  the 
kangaroo  totem  may  sometimes  be  spoken  of  as  a  man-kangaroo 
or  as  a  kangaroo-man.  The  identity  of  the  human  individual 
is  often  sunk  in  that  of  the  animal  or  plant  from  which  he  is 
supposed  to  have  originated."  Spencer  and  Gillen  ("Native 
Tribes  of  Central  Australia,"  quoted  by  J.  G.  Frazer,  loc.  cit., 
"The  Magic  Art,"  Vol.  I.,  p.  107);  "There  was  no  sharp  line 
of  distinction  drawn  either  in  theory  or  in  practice  between  a 
man  and  his  totem." 


ANXIETY-HYSTERIA  83 

chair,  and  seizes  some  food  from  the  table  with  his 
teeth — we  understand.  We  do  not  say,  "  Don't, 
Dickie,"  but  we  pat  the  mettlesome  steed  on  the 
head,  feed  him  from  the  hand  with  lumps  of  sugar 
and  bits  of  apple;  we  softly  rub  his  nose.  We 
understand.  The  father  is  no  longer  everything  that 
is  wonderful  in  strength  and  power ;  there  are  other 
great  spirited  creatures  too.  And,  perchance,  we 
silently  pray :  May  all  future  adaptations  be  as  glee- 
fully and  successfully  accomplished,  as  happily  under- 
stood by  ourselves,  and  as  little  thwarted.6 

This  patient  recovered  under  treatment ;  sleep 
returned,  he  ceased  to  be  disturbed  by  this  particular 
dream  and  vision,  and  therewith  the  physical 
symptoms  subsided.  In  this  case  unfortunately  no 
second  blood-count  was  made,  so  it  cannot  be  said  if 
any  change  is  to  be  recorded.  In  another  case,  how- 
ever (No.  60,  see  p.  38),  there  is  a  record  of  the 
blood-counts  made  when  the  patient  first  came  under 
treatment  and  a  fortnight  later,  when  he  was  much 
improved ;  the  facial  tic  had  then  ceased,  the  eyesight 
was  normal,  and  the  vaso-motor  symptoms  (sweating, 
pollakuria)  troubled  him  no  more. 

Count  on  March  17th,  1916. 
White  cells,  14,000  per  cmm. 
Neutrophile  polyrnorphs,  40  per  cent. 

Small  lymphocytes,            43  „ 

Large  lymphocytes,           13  ,, 

Large  mononuclears,            3  ,, 

Transitionals,                        1  , , 

March  31st,  1916. 

White  cells,  10,750  per  cmm. 
Neutrophile  polymorphs,  35  per  cent. 

Small  lymphocytes,  32  ,, 

Large  lymphocytes,  16  ,, 

Large  mononuclears,          13  ,, 

Transitionals,  4  ,, 

6  For  a  deeper  significance  of  the  symbolic  meaning  of  the 
sacrificial  horse  consult  Jung  ;  "The  Psychology  of  the  Uncon 
scions,"  p.  311-316. 


84  WAR-SHOCK 

The  total  number  of  white  cells  was  much  nearer 
the  normal,  as  was  also  the  percentage  of  small 
lymphocytes,  but  I  am  not  competent  to  discuss  the 
physiological  significance  of  the  blood  changes  in 
these  states. 

Though  it  does  not  come  within  the  scope  of  this 
book  to  treat  in  any  detail  of  the  relationship  between 
the  mind  and  body,  there  are  a  few  points  which  must 
here  be  touched  upon. 

In  the  patient  No.  84  we  have  repressed  fear,  with 
certain  vaso-motor  signs  seen  in  the  emotional  state 
of  fear,  enlargement  of  the  thyroid,  and  alterations 
in  the  constituents  of  the  blood.  Cannon7  has  shown 
experimentally  that  "  clear  evidence  has  been  secured 
that  in  pain  and  deep  emotion  the  glands  [adrenal] 
do,  in  fact,  pour  out  an  excess  of  adrenin  into  the 
circulating  blood."  He  has  shown  that  the  adrenin 
thus  poured  out  in  pain  and  fear  produces  exactly  the 
same  effects  that  follow  an  injection  of  adrenin. 
"  Here,  then,  is  a  remarkable  group  of  phenomena — 
a  pair  of  glands  stimulated  to  activity  in  times  of 
strong  excitement,  and  by  such  nerve  impulses  as 
themselves  produce  at  such  times  profound  changes 
in  the  viscera ;  and  a  secretion  pours  forth  into  the 
blood  stream  by  these  glands,  which  is  capable  of 
inducing  by  itself,  or  of  augmenting,  the  nervous 
influences  which  induce  the  very  changes  in  the  viscera 
which  accompany  suffering  and  the  major  emotions  " 
(p.  64).  "When  adrenin  is  injected  into  the  blood 
it  will  cause  pupils  to  dilate,  hairs  to  stand  erect, 
blood  vessels  to  be  constricted,  the  activities  of  the 
alimentary  canal  to  be  inhibited,  and  sugar  to  be 
liberated  from  the  liver"  (p.  37). 

Cannon  also  suggests   (p.  63)  that    adrenin  may 

7  "Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage,"  by 
Walter  B.  Cannon.  New  York  and  London :  D.  Appleton  and 
Co.,  p.  64. 


ANXIETY-HYSTERIA  85 

co-operate  with  the  products  of  other  glands  of 
internal  secretion ;  the  other  glands  of  internal  secre- 
tion may  be  stimulated  by  sympathetic  impulses 
(p.  65).  We  have  indeed  clinical  evidence  that  the 
thyroid  is  changed  in  these  emotional  states.  It  can 
be  hardly  otherwise,  seeing  the  inter-relationship  of 
these  glandular  secretions,  than  that  there  is  a  stimulus 
of  all  the  glands,  the  glandular  equilibrium  being 
disturbed  throughout. 

It  is  then  conceivable  that  the  alteration  in  the 
blood  cells,  the  lymphocytosis,  is  in  these  cases  a 
secondary  consequence  of  this  repressed  fear  or 
other  emotion.  "  If  these  results,"  says  Cannon,8 
"  are  not  '  worked  off '  by  action,  it  is  conceivable 
that  the  excessive  adrenin  and  sugar  in  the  blood 
may  have  pathological  effects."  I  have  shown 
that  the  emotion  was  not  worked  off  in  this  patient 
(No.  84). 

The  mental  condition  would  be  the  primary  cause 
of  the  disease,  but  it  does  not  follow  that  treatment 
would  necessarily  remove  at  once  all  the  remote 
effects  set  up.  Treatment  directed  to,  say,  any  of 
the  symptoms,  e.g.,  the  enlargement  of  the  thyroid, 
can  produce  excellent  results,  as  Dr.  Florence  A. 
Stoney 9  has  shown ;  if  the  hyperthyroidism  is  subdued, 
the  vaso-motor  symptoms,  which  are  due  to  the  dis- 
turbance in  the  relationship  of  the  internal  secretions, 
will  disappear.  It  seems  not  unlikely  that  the  treat- 
ment by  X  rays,  of  which  she  is  a  strong  advocate, 
likewise  may  influence  favourably  the  primary  cause, 
the  mental  condition.  These  patients,  as  will  be 
gathered  from  No.  84  and  the  others  who  were 
cured  or  improved  by  suggestion,  were  extremely 
suggestible. 

8  Loc.  cit,,  p.  196,  footnote. 

9  Proc.  Roy.  Soc.  of  Med.,  I.e.;  Section  of  Therapeutics, 
p.  50 


86  WAR-SHOCK 

SOMNAMBULISM. 

It  is  difficult  in  some  cases  to  differentiate  a  som- 
nambulism from  that  more  extensive  dissociation  of 
consciousness  known  as  multiple  personality.  The 
difficulty  arises  in  the  following  case,  more  especially 
because  I  lacked  the  opportunity  of  seeing  the  patient 
in  any  of  his  more  pronounced  conditions. 

No.  77.     Aged  31,  a  private  in  the  R.A.M.C. 

Anamnesis.  In  autumn  of  1914  the  hospital  to 
which  he  was  attached  in  France  was  shelled,  and  he 
began  to  suffer  from  headache  and  exhaustion.  In 
January,  1915,  he  was  invalided  for  "neurasthenia." 
In  April,  1915,  he  was  sent  for  duty  to  Malta.  In 
August,  1915,  he  had  an  attack  of  sunstroke,  dropped 
down  unconscious  and  lost  his  memory  for  seven  to 
eight  hours.  After  14  days  in  hospital  he  was  sent 
back  to  England .  In  November,  1 9 1 5,  he  returned  for 
service  to  Malta,  and  whilst  on  hospital  duty  in 
February,  1916,  he  repeatedly  wandered  out  of  the 
tents  at  night  and  "lost  himself"  for  some  hours. 
These  fugues  had  become  very  frequent  of  late. 
He  was  brought  before  his  O.C.,  who  at  once  sent 
him  into  hospital  as  a  patient. 

Examination  a  few  days  later: — 

Frequent  myoclonic  spasms  of  left  face,  neck  and 
shoulder  girdle,  much  less  marked  in  the  left  lower 
limb.  Constant  shrugging  of  left  shoulder.  Pupils 
R.  >L.,  they  react  normally.  Contraction  of  left 
visual  field.  Loss  of  smell  (tobacco)  in  left  nostril, 
and  of  taste  (salt,  sugar)  on  left  side  of  tongue. 
Hearing  less  on  left  side  than  on  right.  A  complete 
left  hemianalgesia.  All  the  movements  of  the  left 
upper  limbs  are  feebler  than  right  and  associated 
with  increase  of  tremor. 

There  is  pain  over  the  cardiac  region  with  palpita- 
tion and  breathlessness.  Tachycardia  was  noted  with 


ANXIETY-HYSTERIA  87 

a  rapid  irregular  pulse  ;  occasional  attacks  of  dyspnoea 
which  are  relieved  by  drawing  a  succession  of  deep 
breaths  with  a  loud  sigh  in  expiration.  There  is  in- 
creased frequency  of  micturition,  but  the  total  amount 
of  urine  passed  in  the  24  hours  is  not  excessive ;  the 
urine  is  normal. 

The  gait  is  normal. 

All  the  reflexes  are  brisk  and  equal. 

He  surfers  from  intense  pains  over  the  back  of  the 
head,  especially  on  the  right  side ;  he  sleeps  badly, 
dozing  for  a  few  minutes  and  waking  up  with  a  start 
and  in  a  profuse  sweat.  The  nights  are  disturbed  by 
nightmares  and  terrors.  He  complains  of  loss  of 
memory  and  of  inability  to  concentrate  his  attention 
either  in  conversation  or  in  reading.  A  walk  of  a  few 
yards  or  the  reading  of  a  few  lines  completely  exhausts 
him.  He  is  in  great  fear  that  he  is  "  going  mad." 

He  is  happily  married  and  has  three  children. 

The  amnesia  is  complete  for  the  earlier  years  of 
his  life,  and  selective  for  later  periods.  There  is  a 
complete  loss  of  memory  of  everything  up  to  the 
age  of  11.  He  knows  that  he  then  left  G.  for 
a  large  town  in  the  North  of  Ireland  where  he 
still  lives.  But  he  remembers  nothing  of  G.  ; 
whether  he  went  to  school  there,  the  kind  of 
house  he  lived  in  and  so  on.  From  that  time  up  till 
the  war  the  memory  is  good,  yet  with  certain  blanks 
as  to  dates,  e.g.,  the  year  of  his  marriage.  He  could 
not  at  once  say  how  many  children  he  had  nor  their 
names.  He  had  forgotten  the  name  of  his  employer 
with  whom  he  had  been  for  some  years.  The 
patient  was  the  manager  of  a  cinema  and  was  in  daily 
association  with  his  employer  on  the  most  friendly 
terms.  These  lapses  of  memory  would  obsess  him, 
and  he  had  various  devices  for  overcoming  the  diffi- 
culty. Half  a  night  he  lay  trying  to  think  of  this 
employer's  name  and  then  recollected  he  had  a 


88  WAR-SHOCK 

photograph  with  his  autograph.  The  name  was  a 
very  common  Scotch  name,  and  was  also  that  of  a 
physician  who  had  seen  him  in  Malta  in  August,  1915, 
and  invalided  him  back  to  England.  The  physician's 
name  was  well  known  to  the  patient  at  the  time  of 
his  illness.  There  were  also  defects  of  what  Mercier l 
calls  the  practical  memory,  and  to  some  extent  one 
could  say  of  this  patient  what  Mercier  writes  of  a 
case  he  quotes  :  "  It  is  for  future  things  that  his 
memory  is  defective."  An  instance  of  this  loss  of 
practical  memory,  or  apraxia,  was  his  inability  to 
strop  a  razor  and  although  shown  he  would  be 
immediately  at  a  loss  how  to  do  it.  (He  was  able  to 
shave  himself.)  He  did  not  know  how  to  lace  up  his 
boots,  and  he  would  forget  all  appointments  in  regard 
to  his  work  as  an  orderly,  the  hours  of  meals,  etc.; 
the  want  of  memory  made  him  oblivious  to  the 
shoulder  tic  and  the  tremors.  As  he  himself  said,  he 
forgot  all  about  it  till  some  one  would  ask  him  how 
his  shoulder  or  face  was.  One  could  almost  say 
that  he  forgot  to  see  with  the  left  eye,  to  hear  with 
the  left  ear,  to  smell  with  the  left  nostril. 

On  several  occasions  the  content  of  consciousness 
had  been  abruptly  broken  and  the  patient  possessed 
by  a  quite  new  stream  of  conscious  ideas.  Such  a 
somnambulism  occurred  for  instance  on  his  return  to 

duty  in  April,  1915.  He  had  left  D in  Ireland 

overnight  on  his  way  to  Aldershot ;  in  London  he  had 
several  hours  to  wait.  Walking  about  he  suddenly 

found  himself  in  V Street,  D ,  with  the  Opera 

House  in  front  of  him.  He  crossed  over  to  a  fruit 
shop  which  he  knew  well,  as  it  was  at  the  corner  of 

his  own  street  (in  D )  and  was  kept  by  a  friend  of 

his,  Mr.  (let  us  say)  Leary.  He  went  in  and  asked  for 
Leary.  The  fruiterer  knew  nothing  about  Leary  and 
a  slight  altercation  arose ;  he  thought  they  were 

1  "  A  Text  Book  of  Insanity,"  2nd  edition,  1914,  p.  106. 


ANXIETY-HYSTERIA  89 

playing  a  stupid  joke  with  him.  He  crossed  back  to 
look  at  the  building  and  was  dazed  to  find  it  was  a 
blank  wall.  He  asked  some  ladies  passing  him  what 
had  become  of  the  Opera  House  and  then  his  mind 
became  quite  blank  till  he  awoke,  quite  himself,  the 
next  morning  in  the  police  station.  The  police  had 
taken  care  of  him  overnight.  He  proceeded  to 
Alder  shot.  He  was  told  about  the  incidents  of  the 
previous  night  and  understood  objectively  what  had 
happened,  but  he  had  never  yet  been  able  to  fit  the 
events  into  the  stream  of  his  conscious  life.  It  was 
no  more  to  him  than  if  he  had  read  a  similar  curious 
story  in  the  newspaper. 

He  was  not  feeling  well  when  he  received  orders 
to  report  for  duty.  He  was  in  a  condition  when,  as 
Mercier2puts  it,  "the  states  which  should  normally 
be  subconscious  are  thus  lifted  into  the  light  of  full 
consciousness,  and  become  subjects  of  attention 
without  direct  guidance  from  the  will,  which  is 
otherwise  engaged."  It  is  easy  here  to  read  into 
the  state  thus  lifted  into  full  consciousness  a  wish- 
fulfilment.  He  wished  to  be  at  home  in  D — — ;  he 

was  at  home  in  D ;  a  fruit  shop  became  the  fruit 

shop  kept  by  his  friend  Leary  at  the  corner  of  his  own 
street ;  the  blank  wall  had  become  the  Opera  House 
of  his  own  city. 

On  another  occasion,  prior  to  his  return  to  Malta 
in  November,  1915,  he  had  been  three  weeks  in 
Aldershot,  when  one  night,  about  ten  o'clock,  he 
dressed  himself,  put  on  his  overcoat,  haversack  and 
water-bottle,  and  reported  himself  in  the  guard  room 
as  having  just  arrived.  He  gave  his  name  correctly, 
drew  his  blankets,  etc.;  on  leaving  the  room  he  was 
recognised  and  conducted  back  to  his  room.  He 
awoke  the  next  morning  with  complete  amnesia  of 

2  C.  Mercier.  Discussion  on  "  Imperative  Ideas."  Brain,  1895, 
p.  329. 


90  WAR-SHOCK 

the  incident  of  the  previous  night.  "  The  next 
morning  I  was  told  about  it  and  was  frightened  of 
myself." 

A  few  days  later  the  same  thing  happened,  when 
he  was  recognised  by  an  orderly  in  the  guard  room. 

Here  again  we  see  the  wish-fulfilment,  the  endea- 
vour to  blot  out  the  three  weeks  in  Aldershot. 

After  the  shelling  of  the  hospital  in  France  (April, 
I9I5)»  be  had  several  hysterical  fugues,  wandering 
from  the  tents  and  hospital  and  "coming  to  himself" 
some  distance  away,  ignoring  how  he  arrived  at  the 
spot,  the  intervening  period  a  complete  blank. 

Minor  instances  of  such  lapses  of  memory  were  of 
frequent  occurrence.  In  a  word-association  test3 
carried  out  with  this  patient,  he,  on  one  occasion, 
gave  68  per  cent,  of  meaningless  reactions  and 
"faults,"  and  a  fortnight  later  41  per  cent. 

The  percentage  of  meaningless  reactions  and 
faults  among  normal  men  of  his  own  class  is  between 
0.9  and  2.4.* 

By  a  meaningless  reaction  is  understood  a  reaction 
which  is  either  not  a  word  at  all  or  not  an  associa- 
tion. The  non-associated  words  are  frequently  the 
name  of  some  object  in  the  room,  as  in  this  patient. 
A  "  fault  "  means  the  absence  of  a  reaction  altogether. 
Thus,  a  series  of  reactions  with  this  patient  ran : 

Stimulus-word.  REACTION. 

Head      Pin  (one  was  on  the  table). 

green     watch  (one  on  my  wrist). 

water     button  (on  uniform). 

/'Pembroke    (name  printed 
p.  ,  \     on  a  box  in  the  "  bunk" 

1     where   test    was   con- 

C     ducted). 


3  For  the  technique  of   this  test,   see   "The  Association 
Method  "  in  Analytical  Psychology.    Opus  cit.,  p.  94,  et  seq. 

4  "The  Associations  of   Normal  Persons,"  by  Jung    and 
Riklin  ;  Chapter  II.  of  "Studies  in  Word- Association."  edited 
by  Dr.  C.  G.  Jung,  translated  by  Dr.  M.  D.  Eder.     London : 
William  Heinemann.    (In  the  Press.) 


ANXIETY-HYSTERIA  91 

Stimulus-word.  REACTION. 

angel 


ship 
pick 
wool 
town 


sea. 


orderly. 

cigarette  (I  was  smoking). 


This  patient  had  made  his  own  way  in  life;  he 
had  a  rather  forceful  personality  and  a  great  love 
of  independence.  His  father  had  been  a  school- 
master in  Scotland,  had  then  gone  into  a  business  in 
Ireland  which  had  been  a  failure.  Soon  after  the 
age  of  twelve  the  patient  began  to  earn  a  living 
and  at  a  very  early  age  he  was  the  main  support  of 
his  parents.  He  was  the  youngest  of  the  family, 
the  other  brothers  and  sisters  had  been  better 
educated  than  himself  and  were  all  in  far  better 
circumstances.  He  was  not  on  friendly  terms  with 
them.  His  father  had  died  some  years  ago,  but  his 
mother,  still  alive,  remained  a  member  of  the  house- 
hold. Although  he  had  been  in  many  trades  he 
succeeded  best  in  work  that  was  connected  with  the 
theatre,  and  for  many  years  he  had  been  engaged 
in  some  way  with  theatrical  life.  Super,  actor,  box- 
room  attendant,  pay-office,  and  finally  manager  of  a 
cinema.  Only  in  this  way  was  he  happy  in  his  work. 

Sublimation.5  The  peculiar  attraction  the  theatre 
had  for  him  showed  itself  to  be  the  sublimation  of 
infantile  exhibitionist  tendencies. 

REGRESSION  OF  THE  LIBIDO. 

To  a  man  of  this  temperament  the  necessary  army 
discipline  was  more  than  irksome.  He  was  a  "unit," 
his  individuality  felt  swamped.  There  was  no  outlet 

5  The  replacement  of  infantile  and  childish  impulses  by 
corresponding  adult  outgrowths  subserving  more  altruistic 
and  ethical  purposes  is  called  sublimation,  when  this  develop- 
ment takes  place  as  normal  growth  from  within,  and  not  by 
compulsion,  by  authority  or  external  pressure.  There  is  no 
"repression  "  in  successful  sublimation. 


92  WAR-SHOCK 

for  the  display  of  his  personality,  for  the  sublimation 
of  his  exhibitionist  tendencies.  His  not  to  reason 
why,  his  but  to  do  as  he  was  told — and  told  by  others 
whom  he  regarded,  whether  rightly  or  wrongly,  as 
inferior  to  himself  in  intellect  and  character.  It  must 
not  be  supposed  that  this  represents  the  patient's 
conscious  attitude  or  that  he  was  in  any  sense 
fractious  or  insubordinate.  Quite  the  contrary  ;  from 
independent  witnesses  (he  had  been  an  orderly  in  the 
hospital)  I  was  able  to  gather  that  he  was  most  faithful 
in  the  fulfilment  of  his  duties — a  model  orderly  in 
every  way — until  his  health  broke  down;  he  had 
never  voiced  any  complaint.  The  conflict  raged 
within,  and  being  debarred  from  reaching  conscious- 
ness, owing  perhaps  to  the  patient's  unusually  high 
sense  of  duty,  it  found  vent  in  phantasies.  Jung6 
says,  "  If  the  individual  consciously  or  unconsciously 
allows  the  libido  (psychical  energy)  to  turn  away  from 
a  certain  essential  task  the  non-used  up  libido  occa- 
sions symptoms  of  a  painful  nature,  oppressing  the 
individual  at  every  turn." 

The  wish  to  regain  his  feeling  of  lost  individuality 
expressed  itself  in  these  attacks  of  somnambulism 
when  he  broke  the  chain  of  consciousness  that  bound 
him  to  the  army  by  the  temporary  assumption  of  his 
former  self.  In  the  attack  he  was  out  of  the  army, 
he  was  b^ick  again  in  his  former  life,  he  was  the 
theatre  manager  or  filled  another  of  his  favourite  roles. 

A  dream  shows  this  desire  for  individual  distinc- 
tion. 

"/  was  in  France  at  some  hall  or  theatre,  a 
hypnotist  was  on  the  stage  with  me.  He  asked  for 
volunteers.  I  went  .  .  .  a  lot  of  bugles.  I  was 
called  to  put  out  a  fire." 

6  "The  Theory  of  Psychoanalysis,"  by  C.  G.  Jung.  New 
York :  Nervous  and  Mental  Disease  Publishing  Company. 
1915. 


ANXIETY-HYSTERIA  93 

The  patient  had  once  taken  part  in  a  rescue  from  a 
fire  and  his  name  had  appeared  in  the  local  paper. 
The  other  associations  showed  that  the  fire  stood  for 
the  display  of  individual  energy,  passion.  (He  knew 
that  I  used  hypnotism  in  the  treatment  of  some 
patients.) 

The  dream  is  an  unconscious  demand  from  those  in 
power  to  allow  him  to  regain  his  individuality ;  he 
wants  to  be  called  upon  to  display  himself,  to  be  a 
leader. 

THE  CHOKING  OF  THE  LIBIDO. 

Among  the  common  symptoms  in  this  choking  of 
the  libido  is  a  return  to  infantile  and  childish  phan- 
tasies, a  regression  to  an  earlier  adaptation  possibly 
long  since  abandoned,  as  in  this  case.  A  dream 
showed  us  in  what  infantile  phantasies  the  libido  was 
now  engaged. 

"  /  was  going  to  be  hung.  I  was  working  at  some 
hospital  in  France,  with  a  German  patient.  I  shot 
him  with  a  revolver.  I  was  put  in  a  cellar  and  was 
brought  out  to  be  hung." 

The  German  patient  turned  out  to  be  an  older 
brother  ;  the  rest  of  the  dream  was  a  typical  one 
and  will  be  understood  by  those  acquainted  with 
symbolic  language.  Its  full  explanation  would  re- 
quire a  detailed  exposition  that  would  take  us  beyond 
the  scope  of  the  book.  The  last  dream  he  brought 
me  in  analysis,  just  before  he  was  transferred  home, 
ran: — 

"  /  was  carried  on  a  stretcher  to  the  eye  bunk  and 
you  were  there,  but  you  went  out  and  left  me.  I 
tried  to  run  after,  but  could  not  move  any  part  oj 
me." 

(My  work  was  carried  out  in  the  "eye  bunk.") 

The  analysis  showed  that  this  paralysis  expressed 
his  double -sided  (ambivalent  as  Bleuler  calls  it) 


9  WAR-SHOCK 

attitude  towards  leaving  me.  He  wanted  the  treat- 
ment to  continue,  so  that  in  the  dream  he  is  very  ill 
and  must  be  carried.  (The  patient  was  really  up  and 
dressed.)  I  leave  him,  it  is  my  fault,  as  it  were,  that 
his  treatment  is  to  stop.  He  wants  me.  But  he 
also  wants  to  go  home.  Hence  the  paralysis — a 
mental  indecision. 

The  shrugging  shoulder  (again  left-sided)  turned 
out  to  be  a  rather  unusual  form  of  symbolic  conver- 
sion.  It  expressed  disapproval  of  his  own  uncon- 
scious phantasies. 

The  patient  was  under  psycho-analytic  treatment 
for  four  weeks ;  this  had  resulted  in  improvement  in 
his  symptoms.  The  hysterical  stigmata  had  left,  the 
tic  was  much  less  frequent  and  violent.  His  burning 
headache  had  ceased  and  he  was  sleeping  better  (no 
hypnotic  drugs  had  been  given  throughout).  The 
somnambulistic  attacks  had  gone  and  he  was  beginning 
to  concentrate ;  he  could  read  a  paper  and  write  a 
letter;  he  brought  me  some  verses  he  had  written. 

But  the  analysis  was  incomplete,  and  the  patient's 
unconsciousness  had  recognised,  as  his  dream  showed, 
that  he  was  not  cured  and  required  further  treatment. 
I  feared  he  would  relapse  before  very  long.  Such 
improvement  is  not  infrequent  in  the  early  stages  of 
analysis,  and  has  too  often  deceived  both  patient  and 
doctor.7 

7  I  heard  from  this  patient  some  time  later.  He  was  still  in 
hospital  having  a  rest  cure !  Some  of  the  symptoms,  as  I  feared, 
had  returned. 


CHAPTER  V 

PSYCHASTHENIA 

THE  name  given  by  Janet  calls  attention  to  one  of 
the  most  prominent  clinical  symptoms  in  these  cases, 
the  intense  exhaustion,  as  Freud's  term,  obsessional 
neurosis,  rivets  attention  upon  another  of  the  main 
clinical  features.  I  have  retained  Janet's  designation 
because  it  is  the  better  known,  and  had  I  adopted  an 
unfamiliar  name  for  this  group  of  diseases  I  should 
have  fashioned  one  that  fastens  upon  a  deeper  psycho- 
logical aspect.  But,  for  reasons  already  given,  the 
psycho-analysis  of  none  of  my  patients  was  complete 
and  the  results  given  in  this  chapter  are  too  meagre 
to  add  much  strength  to  any  far-reaching  psychologi- 
cal conclusions.  Still,  some  of  the  analyses  do,  I 
think,  offer  evidence  in  support  of  Jung's1  intro- 
version theory  as  well  as  to  a  further  conception 
which  I  will  leave  unnamed. 

COLLECTING    MANIA — FEAR — PSYCHIC 
AMBISEXUALITY. 

No.  95  was  living  in  a  north-eastern  town  that 
was  bombarded  in  December,  1914.  A  shell  came 
through  the  roof  of  a  house  where  he  was  staying  with 
his  wife,  child  and  father.  No  one  was  hurt,  but  for 
the  next  three  weeks  he  was  quite  "  broken  down." 
He  could  not  undress  nor  go  to  bed  at  night,  but  slept 

1  Analytical  Psychology,  op.  cit.,  p.  847. 

95 


96  WAR-SHOCK 

fitfully  in  a  chair.  He  was  "  all  of  a  tremble"  and 
started  at  the  least  noise,  breaking  into  a  fit  of  crying 
at  the  slightest  provocation  or  at  none.  His  wife 
used  to  comfort  him.  He  gradually  got  better  "in 
himself "  but  still  felt  very  nervous  and  trembling ; 
he  was  afterwards  afraid  to  drive  a  motor  bicycle  or 
a  horse  and  cart,  both  used  in  his  business.  Never- 
theless he  felt  he  must  "do  his  bit"  and  enlisted  in 
August,  1915,  in  the  A.S.C.  motor  transport  but 
broke  down  right  away.  He  was  to  be  retained  for 
home  service,  but  implored  his  C.O.  to  give  him  a 
chance  of  serving  abroad.  He  was  sent  to  Salonica. 
It  was  found  that  he  was  too  nervous  to  drive  and 
he  was  given  work  in  the  stores  until,  owing  to  in- 
attention, he  made  some  mistakes  and  was  kept  for 
odd  jobs,  such  as  clearing  the  rubbish  away  round 
the  tent,  removing  stones.  He  had  a  fit  and  was 
sent  into  hospital. 

When  he  came  under  observation  in  February,  1916, 
he  was  suffering  from  sleeplessness,  inability  to  fix  his 
attention,  terror  so  extreme  that  if  a  motor  went  by 
the  hospital  grounds  he  would  scuttle  under  the  bed. 
With  difficulty  could  he  be  persuaded  to  take  off  his 
clothes  at  night ;  he  had  a  "  collecting  mania," having 
gathered  several  bags  of  cigarette  pictures  for  his 
little  girl  and  bags  of  stones  from  the  shore.  The 
fear  of  Zeppelins  was  obsessional.  The  Sister  coming 
in  with  a  lantern  was  sufficient  to  send  him  under  the 
bed ;  another  obsession  was  that  he  would  be  accused 
of  stealing,  e.g.  his  own  uniform  and  boots,  since  he 
had  done  no  fighting. 

There  was  analgesia  of  both  legs  to  the  knees  and 
of  the  left  arm  to  the  shoulder.  There  was  no  history 
of  previous  nerve  trouble ;  he  was  happily  married, 
in  a  decent  position,  a  total  abstainer ;  he  had  often 
taken  part  in  boxing  competitions  and  cycle  racing. 
(His  "  legs  used  to  get  excited  before  a  fight.") 


PSYCHASTHENIA  97 

This  patient  showed  his  grit  by  enlisting  voluntarily, 
against  the  wishes  of  his  wife,  family  and  friends, 
and  by  getting  abroad  ;  a  strange  contrast  with  his  con- 
dition of  fear  and  terror.  The  following  two  dreams 
throw  light  on  this  contrast. 

Dream.  He  was  at  home  dressed  as  a  High- 
lander and  saw  his  little  girl  who  did  laugh — so  did 
he, 

Dream  two  days  later.  He  was  a  Chinaman  in 
native  dress,  with  a  long  pigtail;  beautifully  long 
hair  right  to  the  floor, 

No  analysis  of  the  dreams  was  made  (nor,  of  course, 
any  interpretation  given  to  the  patient).  These  are 
typical  dreams  of  being  or  desiring  to  be  female. 
The  Highlander's  kilt  is  a  disguise  under  which  the 
endopsychic  censor  permits  such  unconscious  wishes 
to  appear  in  consciousness  without  betrayal.  A 
Chinaman  is  perhaps  more  tell-tale  ;  Europeans  pro- 
verbially find  it  difficult  to  distinguish  a  Chinese  man 
from  a  woman,  on  account  of  the  flowing  robes,  the 
lack  of  hair  on  the  face,  etc.;  in  this  dream  the 
pigtail,  as  if  the  latent  meaning  was  trying  to  get 
expression,  was  beautiful  and  long,  reaching  to  the 
ground.  - 

It  is  important  to  note  that  the  "  dream- work  "  aims 
primarily  at  disguising  the  meaning  of  the  dream,  or 
its  latent  content,  from  the  dreamer  himself  ;  the 
censor  is  much  less  concerned  with  concealing  its 
significance  from  third  persons.  The  symbolism  here 
used,  though  plain  enough  to  myself,  was  quite 
effectual  so  far  as  the  dreamer  was  concerned.  It  is 
probable  that  if  the  first  of  these  two  dreams  had  been 
analysed  in  the  usual  way  and  the  dreamer  had 

2  It  must  not  be  assumed  that  a  Chinaman  invariably  stands 
for  "woman.''  There  might  be,  of  course,  some  specific 
memory.  I  am  only  dealing  with  it  when  it  is  a  universal,  not 
a  particular,  symbol. 

H 


98  WAR-SHOCK 

realised  its  significance,  the  second  dream  would  not 
have  occurred,  or  very  different  symbols  would  have 
been  used. 

The  reading  of  this  dream  shows,  as  I  have  said, 
a  concealed  wish  to  be  a  woman ;  he  is  psychically  a 
woman.  This  gives  the  clue  to  the  patient's  exces- 
sive emotivity,  his  exaggerated  fears,  his  "  woman's  " 
heart  that  burst  out  crying  if  he  saw  a  child  in 
the  street.  The  primitive  unconscious  is  wont  to 
exaggerate  any  part,  especially  to  overact  its  popular 
attributes.  If  a  woman  may  be  regarded,  without 
prejudice,  as  the  lawyers  say,  as  a  more  timorous 
creature  than  the  male,  then  the  unconscious  repressed 
female  in  a  male  exhibits  fear  greater  than  was  ever 
shown  by  any  woman ;  if  a  woman  is  popularly  taken 
or  typically  regarded  as  having  motherly  feelings 
towards  any  child,  then  the  female  suppressed  in  the 
male  weeps  bitterly  over  every  passing  child. 

It  is  a  case  of  ambisexuality,  the  male  side  being 
shown  by  the  desire  to  share  in  the  fighting.  The 
origin  of  this  exaggerated  psychic  ambisexuality  was 
not  discovered,  for  no  deep  analysis  was  made,  though 
the  anamnesis  and  some  other  dreams  threw  some 
light  on  the  problem. 

The  "  collecting  mania "  was  connected  with  a 
money-complex.  His  father,  beginning  life  very 
humbly,  had  amassed  quite  a  respectable  sum  of 
money.  This  patient  felt  a  desire  to  amass  money 
like  his  father,  to  have  his  father's  money — so  that 
there  was  an  under  feeling  of  bitterness  and  rivalry 
towards  his  father.  This  found  conscious  compensa- 
tion in  the  most  exaggerated  praise  of  his  father  and 
of  the  patient's  wonderful  goodness  as  a  boy  and 
man  towards  his  father,  of  extreme  punctiliousness  in 
money  matters ;  see,  for  instance,  his  doubt  whether 
he  should  not  return  his  pay  to  the  State  since  he  had 
done  no  soldiering,  which  co-existed  with  singularly 


PSYCHASTHENIA  99 

naive  reckonings  as  to  how  much  he  would  be  able  to 
draw  by  the  time  he  reached  England. 

The  result  of  treatment  by  hypnotic  suggestion 
is  very  interesting;  he  was  easily  hypnotised  and 
responded  readily  enough  to  suggestion  under 
hypnosis  but  post  -  hypnotic  influence  was  for  a 
time  altogether  absent.  His  fears  remained,  his 
excessive  emotivity,  sleeplessness,  and  so  on. 
We  continued  our  psychological  investigations 
(diagnostic  psycho-analysis  as  it  may  be  called)  and 
he  brought  me  the  material  briefly  summarised  here 
together  with  the  dreams.  I  then  used  the  know- 
ledge, deduced  from  the  psychological  examination, 
under  hypnosis,  telling  him  that  he  was  no  longer  to 
act  the  timid  female,  that  his  womanly  side  would 
quite  go,  that  he  was  a  vigorous  male,  that  he  had  no 
exaggerated  female  characteristics,  that  he  did  not 
want  to  bear  children  (another  dream  showed  this 
phantasy),  but  to  be  the  father  of  children  and  so  on. 

He  re-acted  post-hypnotically  to  these  suggestions ; 
from  that  time  (the  sessions  were  repeated)  the  fears 
began  to  diminish  and  finally  disappeared.  The  next 
day  he  proudly  told  me  that  he  had  brushed  his  boots — 
the  first  time  since  leaving  England,  nearly  two 
months  ago.  He  no  longer  scuttled  under  the  bed  if 
he  heard  a  motor-horn ;  the  analgesia  disappeared. 
This  case  shows  the  advantage  of  knowing  what 
suggestion  to  give  in  difficult  cases ;  in  easy  cases,  of 
course,  the  stereotyped  suggestion  answers  well 
enough.  To  obtain  the  information  required  for 
accurate  suggestion  we  can  apply  the  results  of 
psycho-analytic  knowledge  to  our  patients'  symptoms 
history  and  dreams.  In  the  waking  state  this  patient 
was  not  aware  of  the  suggestions  that  had  been  made 
to  him  during  hypnosis,  upon  which  he  subsequently 
acted.  He  knows  nothing  to  this  day  about  the 
possession  of  a  money-complex,  of  his  unconscious 


100  WAR-SHOCK 

attitude   to   his   father,   or   of  his   strongly  marked 
female  side. 

FEAR  CONTENDING  WITH  DESIRE 

The  following  is  but  a  fragmentary  history;  I  have 
included  it  because,  incomplete  though  it  is,  it  presents 
a  not  uncommon  psychological  attitude. 

No.    100    was  admitted  for  physical  and  mental 
exhaustion  and  insomnia.     There  were  no  physical 
signs.     All  he  wanted  to  do,  as  he  put  it,  was  to  lie 
coiled  up  in  bed;  it  was  an  effort  to  think,  it  was  an 
effort  to  eat,  it  was  an  effort  to  turn  round  in    bed ; 
he  did  not  want  to  become  aware  that  he  had  legs 
or  hands.     It  was  not  the  condition  of  apathy  as  seen 
in  melancholia.     He  wanted  to  lie  coiled  up  in  bed, 
but    he   could   not;   he   could   not   prevent   himself 
being   stirred    into    some   kind   of   activity   by    his 
surroundings;  conversation    would   trick   him,    as  it 
were,  into   a  discussion;  then  he   would   think  this 
activity  was  injurious  and  would  fall  into   silence. 
"  I'm  tired  out,  and  though  I  spend  most  of  my  days 
in  bed,  it  is  without  rest  or  sleep."     "  I  feel  I  have 
to   go   through   the   whole   weary   business  again." 
"  What's  your  name,  age,  service — what's  the  matter 
with  you  ?     Why  can't  you  sleep  ?     I'm  simply  too 
tired  to  bother  with  it  all," — was  his  feeling  on  admis- 
sion to  our  department.     The  patient  was  28  ;  he 
had  been  married  subsequent  to  joining  the  army. 
He  had  joined  the  service  in  the  autumn  of  1914,  his 
health  not  being  good  enough  to  join  at  the  beginning 
of  the  war,  and  had  risen  rapidly  to   high  N.C.O. 
rank.     He  had  seen  service  in  France  and  the  East. 
He  was  much  worried  about  the  relationship  between 
himself  and  his  commanding  officer — a  recent  appoint- 
ment— whom  my  patient  believed  was  trying  to  get 
him  reduced  in  rank.     That  the  patient  had   risen 
from  merit  alone  was  clear ;  he  had  no  Army  friends. 


PSYCHASTHENIA  101 

He  had  been  educated  at  a  public  school  and  had 
afterwards  had  good  appointments  in  the  Colonies, 
having  returned  to  England  two  years  before  the  war 
for  family  reasons.  The  work  abroad  was  rather 
responsible,  of  a  nature  calling  for  much  individuality 
and  management  of  subordinates.  It  was  doubtless 
to  this  training,  combined  with  great  natural  gifts, 
that  he  owed  his  rise. 

There  had  been  three  similar  attacks  of  illness 
before  the  war,  in  fact  he  was  convalescing  when  the 
war  broke  out. 

The  family  history  was  medically  not  good.  His 
had  been  a  solitary  life ;  he  had  had  but  one  friend  at 
school  and  later  in  life  found  it  difficult  to  get  into 
touch  with  men  and  women.  Like  so  many  in  similar 
case  life  never  seemed  wholly  real  to  him  ;  he  had 
drifted  along.  With  many  abilities,  he  had  not 
hitherto  found  his  niche  in  the  world  ;  "  people  did 
not  understand  him."  The  home  life  had  not  been 
a  happy  one;  between  himself  and  his  father  there 
had  always  been  opposition  ;  he  was  out  of  touch 
with  his  mother  and  sisters.  He  had  become  in- 
terested in  ideas  and  social  reforms,  especially  in 
sexual  problems.  Frankness  between  the  sexes  he 
was  wont  to  regard  as  the  first  desideratum  and  he 
claimed  that  he  had  been  able  to  establish  this  with 
the  one  or  two  women  he  had  known  at  all  inti- 
mately ;  "  a  platonic  relationship"  on  this  basis  had 
been  his  ideal.  He  had  kept  himself  pure  and  had 
never  indulged  in  the  mildest  flirtation.  He  had  a 
horror  of  sex  and  he  complained  that  the  language  of 
the  barrack-room  and  the  camp  was  filthy.  He 
found  that  women  and  sex  were  the  only  topics  of 
conversation  and  it  was  the  one  theme  he  wanted  to 
shun  unless  it  could  be  discussed  in  an  entirely 
rational  and  scientific  spirit,  as  he  complained  it 
never  was.  He  had,  during  his  stay  in  parts  of  the 


102  WAR-SHOCK 

world  notorious  for  their  license,  kept  himself  un- 
spotted— chiefly,  he  believed,  for  a  girl  whom  he 
had  known  in  England — the  first  woman  outside  the 
home  circle  he  had  known ;  she  had  been  the  main 
factor  in  bringing  him  away  from  the  cramped 
and  rather  sordid  home  atmosphere.  She  (and  her 
brother)  had  inspired  him  with  ideals  of  life,  had 
awakened  a  certain  literary  instinct  and  had  urged 
him  towards  a  higher  life.  There  was  no  question 
of  marriage  with  this  lady,  who  was  some  years 
older,  and  with  her  he  had  never  discussed  the 
sexual  problem  in  any  way. 

On  the  surface  there  was  this  pure  and  rational 
attitude  towards  sex;  but  beneath  there  was  a 
raging  torrent  of  desire  which  had  never  found  any 
outlet,  of  course  a  not  very  uncommon  position. 

"  More  than  I,  if  truth  were  told, 
Have  stood  and  sweated  hot  and  cold, 
And  through  their  veins  in  ice  and  fire, 
Fear  contended  with  desire." 

It  was  in  compensation  for  this  ill-regulated  sexual 
life  in  the  unconscious  that  he  became  so  horrified 
at  the  common  attitude  towards  sex.  He  found  the 
talk  of  the  barrack -room  and  the  camp  filled  with 
nothing  but  woman  and  sex  because  it  was  the  only 
talk  which  at  once  attracted  his  attention — he  was 
unconsciously  on  the  quivivefor  every  allusion  to  sex. 
Those  acquainted  with  the  life  among  soldiers  will 
know  that  sex-talk  is  no  more  rampant  among  them 
than  among  any  other  body  of  men.  From  an 
experience  gained  in  three  different  campaigns  with 
soldiers,  British  and  non-British,  in  very  different 
countries  and  under  very  different  conditions,  I  have 
found  the  interests  of  the  soldier  as  wide  as  life  itself 
— at  all  events  on  active  service  where  only  I  have 
been  intimately  associated  with  them  and  this  most 
intimately,  for  a  long  sojourn  in  a  besieged  up-river 


PSYCHASTHENIA  103 

post  produces  the  closest  associations  with  one's 
fellow-sufferers.  To  one  who  has  lived  with  men 
when  they  were  doing  the  real  fighting  it  is  in- 
teresting to  contrast  the  poetry  written  by  warlike 
poets  with  that  written  by  poet  warriors.3 

In  our  patient  it  was  then  this  fear  of  sex  that  led 
him  to  try  and  put  it  on  a  rational  basis.  It  was  his 
own  sexual  problem  that  he  must  solve  ;  as  is  so 
frequently  the  case,  his  individual  need  became 
identified  with  the  general  need. 

As  type  of  his  early  adolescent  phantasies  the 
following  may  be  given.  He  would  imagine  that  his 
two  schoolmistresses  (much  older  than  himself)  were 
naked  and  he  was  driving  them  along  whipping 
them,  or  he  was  bathing  with  them  naked  and 
striking  them.  Similar  phantasies  occurred  with 
others,  e.g.,  with  a  little  girl  of  his  own  age  and 
with  a  typist  engaged  in  an  office  with  him.  (Never 
had  he  phantasies  with  the  ideal  Miss  X.)  His  frank 
discussions  with  women  had  never  led  him  to  the 
disclosure  of  these  and  similar  phantasies  that  had 
haunted  him  for  years. 

A  dream  will  show  the  nature  of  some  of  these 
phantasies. 

On  a  boat  running  out  of  A —  Harbour,  going 
down  the  River  B — .  *  We  went  through  a  narrow 
passage  which  came  gradually  to  a  point,  and  got 
stuck  in  the  mud.  Ship  did  not  stop.  Looking  out 
of  the  port  hole  window  I  saw  a  Zeppelin  in  the  dis- 
tance. It  was  attacked  by  a  fleet  of  balloons.  One 
burst  and  all  the  bits  came  dropping  through  the  air. 

3  Compare  Kipling's  "Barrack  Room  Ballads"  with  the 
gallant  Grenf  ell's  -'Into  Battle  "  or  the  writings  of  journalists 
safe  at  home  like  Bottomley  and  Blatchford  with  the  works 
of  actual  fighters  like  Boyd  Cable  and  the  author  of  "A 
Student  in  Arms." 

4  I  omit  the  names  of  these  places  to  prevent  identification 
of  the  patient. 


104  WAR-SHOCK 

One  end  of  the  Zeppelin  was  dropping  but  it  rose  and 
woke  me  up  with  a  start. 

The  patient  was  totally  unacquainted  with  psycho- 
analytic literature  ;  he  did  not  even  know  that  he 
was  being  analysed ;  and,  of  course,  no  sugges- 
tion was  made  to  him  as  to  what  might  be 
the  meaning  of  the  dream.  He  was,  however,  well 
read  in  the  Bible  and  other  literature,  so  that  with 
symbolic  language  he  was  at  home.  His  associations 
to  the  incidents  as  described  in  the  dream  soon 
brought  him  to  an  appreciation  of  the  symbols  he  had 
used.  He  discovered  that  the  narrow  passage  stood 
for  the  vagina  and  that  the  mud  was  the  anal  region  ; 
that  the  boat  coming  down  the  passage  (the  vagina) 
was  himself  (cf. ,  the  birth  of  Moses,  of  Ra,  and  other 
legendary  heroes  discovered  in  infancy  floating  in 
barks  on  water). 

When  by  association  he  had  identified  the  balloon 
as  the  womb  and  the  Zeppelin  as  the  phallus,  and 
further  associations  showed  that  it  was  his  mother's 
womb  and  his  own  phallus,  the  dream  got  a  meaning 
for  him.  Birth  is  per  anum  or  at  least  closely  con- 
nected with  that  region  of  "  filth."  The  sexual  act 
is  filthy  like  the  act  of  defalcation ;  as  another  patient 
once  put  it  to  me,  coitus  was  just  the  same  as  going 
to  the  w.c.,  to  be  performed  on  the  same  hygienic 
ground.  His  phallus  (Zeppelin)  is  the  prey  of  women 
(balloon)  which  will  destroy  his  male  power. 

The  further  motive  of  the  dream  was  then  brought 
home  to  him.  For  him  sexuality  is  a  sin  derived 
from  the  woman;  "Through  the  woman  came  sin. 
The  woman  tempted  me  and  I  did  eat."  The  mean- 
ing being  that  he  would  ascribe  the  blame  for  his 
difficulty  in  overcoming  the  adaptation  to  a  normal 
life  to  the  mother — this  is  the  CEdipus  motiv. 
Jung  writes : 5  "  The  neurotic  who  cannot  leave 
5  "  Psychology  of  the  Unconscious."  Op.  cit.,  p.  304. 


PSYCHASTHENIA  105 

the  mother  has  good  reasons  ;  the  fear  of  death 
holds  him.  It  seems  as  if  no  idea  and  no  word  were 
strong  enough  to  express  the  meaning  of  this.  Entire 
religions  were  constructed  in  order  to  give  words  to 
the  immensity  of  this  conflict.  The  struggle  for 
expression  which  continued  down  through  the  cen- 
turies certainly  cannot  have  its  source  in  the  restricted 
realm  of  the  vulgar  conception  of  incest.  Rather  one 
must  understand  the  law  which  is  ultimately  expressed 
as  incest  prohibition,  as  coercion  to  domestication, 
and  consider  the  religious  systems  as  institutions 
which  first  receive,  then  organise  and  gradually 
sublimate,  the  motor  forces  of  the  animal  nature  not 
immediately  available  for  cultural  purposes." 

With  this  dream  we  may  take  a  later  one. 

"  With  my  mother  in  house  in  B.  (town  where  he 
was  born).  We  went  for  a  walk  and  coming  back 
I  saw  the  house  was  on  fire.  Mother  said,  '  We've 
saved  our  wedding  presents!  I  asked  if  my  books 
were  saved,  but  they  had  all  been  burnt}* 

This  dream  requires  some  explanation.  The 
patient  in  the  anamesis  had  at  first  dilated 
upon  the  joy  he  had  found  in  the  marriage  state: 
for  the  first  time  there  had  been  complete  harmony 
in  his  life.  Analysis  had  shown  that  in  reality  the 
patient  had  been  bitterly  disappointed  ;  marriage 
was  wholly  distasteful  and  abhorrent.  He  had  tried 
to  overcome  this  repugnance  and  to  make  love 
become  the  rapture  depicted  by  poets  and  novelists. 
He  had  thought  that  it  was  treachery  to  his  bride  to 
acknowledge  even  to  himself  his  misgivings  and 
vainly  hoped  with  time  the  union  would  bring  him, 
if  not  real  happiness,  at  least  contentment  or  that 
perhaps  death  in  battle  would  solve  the  riddle. 

What  had  rushed  him  into  marriage  did  not 
become  quite  clear,  but  it  is  to  be  remembered  that 
the  army  life  gave  him  for  a  time  certain  satisfac- 


106  WAR-SHOCK 

tions  (compare  his  phantasies),  that  at  first  he  was 
able  to  forget  himself  and  to  become  more  normal. 
It  was  shortly  after  joining  that  he  had  his  first 
amorous  adventure;  he  took  a  young  lady,  whom 
he  accidentally  met,  to  some  entertainment  and  went 
so  far  as  to  put  his  arm  round  her  waist.  There  was 
a  revulsion  of  feeling  the  next  day  but  it  was  not 
long  afterwards  that  he  became  engaged  (not  to 
this  girl)  and  was  married.  He  was  perhaps 
carried  away  in  this  almost  adolescent  state  by 
what  Mr.  H.  G.  Wells  would  call  the  enterprising 
female. 

Now  the  patient  understood  that  he  was  imper- 
fectly developed,  despite  the  rather  wandering  life 
he  had  led  and  the  Army  experiences  ;  he  knew 
himself  to  be  quite  immature  and,  like  Peter  Pan, 
he  did  not  want  to  grow  up. 

Knowing  that  I  could  only  treat  the  patient  for 
a  very  short  time,  I  did  rather  hurry  him,  but  he  was 
very  intelligent  and  his  unconscious  in  a  receptive 
mood.  He  understood  that  relationship  between  his 
wife  and  himself  would  not  be  satisfactory  until  he 
swept  away  all  dishonesties  from  himself,  that  the 
first  step  towards  a  real  life  in  common  was  to  do 
away  with  his  pretended  raptures  and  literary  make- 
beliefs.  Courage  to  face  himself  was  the  primary 
need.  There  followed  48  hours  of  acute  misery — 
and  then  the  dream — his  books  were  destroyed — the 
mannerisms  which  were  only  plumes  borrowed  from 
others,  were  ended.  Having  divested  himself  of  what 
was  so  merely  external  he  must  meet  the  world 
with  his  own  resources.  The  dream  suggests  that 
there  is  in  the  unconscious  no  clear  distinction 
between  his  wife  and  his  mother;  the  house,  his 
early  home,  like  the  city,  is  "a  maternal  symbol, 
a  woman  who  fosters  the  inhabitants  as  children."6 
6  Jung,  op.  cit.,  p.  224. 


PSYCHASTHENIA  107 

Fire  is  a  well-known  symbol  of  passion,  of  the 
libido.7 

The  patient  has  gone  a  little  way  on  the  path  to 
reality ;  he  has  discovered  that  his  libido  is  still 
attached  to  his  mother  and  that  he  must  free  himself 
therefrom  before  he  can  overcome  his  fear  of  sex. 
That  fear  overcome,  he  will  be  ready  for  the  next 
stage  in  his  development — sex  will  no  longer  fill  the 
overwhelming  role  that  it  at  present  does  in  this 
masked  fashion. 

The  process  of  self-deception  must  end  if  any 
harmony  is  to  be  established.  We  can  understand 
that  with  this  tremendous  conflict  of  emotion  raging 
within  him  the  patient  should  be  exhausted.  There 
is  inertia  because  the  fight  for  reality  loomed  so 
terribly  in  front  of  him.  There  was  no  time  to  make 
a  complete  analysis,  of  course,  nor  to  help  the 
synthesis.  It  remains,  as  I  said,  a  fragment,  but  the 
history  suggests  that  sex  must  be  on  a  satisfactory 
footing  before  the  individual  aim  can  be  discovered 
or  have  any  value.  In  some  cases  the  understanding 
of  the  sexual  life  will  be  sufficient  in  itself  to  bring 
about  a  normal  if  somewhat  restricted  life. 

IDIO-KINESIS. 

No.  99.  The  patient  is  a  married  man,  aged  29, 
a  private  of  some  months'  service,  who,  after  three 
months  in  France,  was  sent  to  Salonica,  where  he 
was  invalided  for  severe  and  persistent  backache, 
insomnia,  and  occasional  enuresis.  On  Feb.  5th, 
1916,  he  presented  a  widespread  analgesia,  with 
odd  normal  patches,  and  a  zone  of  hyperaesthesia 
in  the  lumbar  region.  It  is  his  mental  condition, 
however,  that  will  be  here  dealt  with.  There  were 
sleeplessness,  general  restlessness,  inability  to  fix  his 
attention  on  anything  for  more  than  a  few  minutes. 
1  Jung,  op.  cit.,  p.  162,  et  seq, 


io8  WAR-SHOCK 

In  conversation  with  his  mates  he  would,  for  instance, 
be  suddenly  quite  oblivious  of  what  they  had  been 
talking  about  and  feel  uncertain  whether  he  had 
spoken  or  not.  He  read  for  a  few  lines  and  would 
throw  down  the  paper.  In  writing  home  he  once 
told  me  that  he  had  begun  twenty  letters,  destroying 
each,  and  then  finished  a  few  lines.  He  was  so 
"  shy  "  that  he  could  only  with  difficulty  walk  along 
the  hospital  grounds,  feeling  then  that  everybody 
was  looking  at  him.  He  had  found  it  impossible  to 
number  off  in  the  ranks,  and  had  he  to  address  his 
commanding  officer  he  would  become  speechless. 
He  was  morbidly  anxious  about  his  family;  though 
he  had  no  reason  to  suspect  illness,  he  would  carry 
a  letter  from  his  wife  two  or  three  days  in  his 
pocket  before  venturing  to  open  it,  lest  there  should 
be  bad  news. 

There  were  numerous  obsessions  or  eccentricities. 
In  walking  he  must  mark  each  flagstone  and  touch 
each  post.  He  had  the  impulse  to  count  and  to 
arrange  things  in  patterns,  counting  on  his  fingers  or 
the  panes  of  windows  in  the  rooms  and  arranging  them 
in  sets  of  twos,  threes,  etc.  An  obsession  that  came 
to  light  was  an  impossibility  to  go  into  a  shop  or 
restaurant  alone.  By  dint  of  great  effort  he  could 
thrust  himself  into  a  hosier's  or  tailor's  shop  alone, 
after  a  careful  survey  to  ascertain  that  no  other  cus- 
tomers were  present.  This  peculiarity  was  the  cause 
of  numerous  embarrassments.  His  wife,  to  whom  he 
was  ashamed  to  confide  the  trouble,  would  ask  him 
to  buy  something  when  he  was  going  out.  He  would 
assent,  realising  at  the  same  time  the  impossibility 
of  the  task,  and  already  inventing  some  lame  excuse 
to  be  presented  on  his  return.  Often  had  he  gone 
without  a  meal  when  motoring  alone  because  he  could 
not  face  going  into  a  restaurant. 

At  times  a  cloud  seemed  to  come  over  him  and  he 


PSYCHASTHENIA  109 

did  not  seem  in  the  world  at  all,  but  was  without,  a 
spectator  watching  and  but  dimly  interested  in  the 
movements  of  men  and  women,  himself  included.  He 
was  a  Public  School  man,  with  a  well-developed  and 
subtle  intellect ;  he  was  well  oriented  in  space  and 
time.  He  realised  quite  well  the  absurdity  of  his 
obsessions,  and,  as  he  said  to  me,  "I  know  I'm  a 
damned  fool  and  it's  rot,  but  there  it  is,  I  cannot 
help  myself." 

We  learn  from  his  history: — That  he  had  never 
done  any  work  since  he  left  school  at  18  until  he  joined 
the  Army  as  a  private.  He  had  substantial  private 
means.  He  had  been  married  three  and  a  half  years 
and  had  a  son  and  was  devotedly  (morbidly?) 
attached  to  wife  and  child.  His  time  had  been 
engaged  in  travelling  about  the  world,  in  various 
sports;  he  was  an  excellent  shot  and  was  selected 
for  sniping  in  France,  where  his  "bags  "  brought  him 
great  credit.  He  was  the  son  of  a  well-to-do  ship- 
builder and  from  the  earliest  days  was  passionately 
interested  in  ships  and  engineering.  His  school 
holidays  were  chiefly  spent  in  his  father's  or  the 
adjoining  yards,  where  he  was  always  planning,  and 
later  on  designing,  new  kinds  of  ships  and  engines 
never  to  be  used.  During  his  boyhood's  holidays  he 
would  accompany  his  father  on  business  journeys  and 
would  sit  in  the  customers'  office  whilst  business 
transactions  were  carried  on — always,  in  his  own 
words,  "  gloating  with  joy  at  his  father's  cleverness 
and  talk."  From  about  six,  or  perhaps  earlier,  up 
till  the  age  of  eleven,  he  slept  with  his  father  in  the 
same  bed.  He  had  a  proper  affection  for  his  mother, 
but  it  was  a  pale  reflection  of  the  worship  of  his 
father. 

He  passed  creditably  through  school,  did  quite 
well  at  games,  and  it  was  understood  that  he  would 
enter  his  father's  business .  On  leaving  school  his  father 


no  WAR-SHOCK 

said  :  No  need  to  hurry  about  business,  take  a  couple 
of  years  and  see  the  world.  After  two  years  he  returned 
ready  and  anxious  to  enter  business.  But  the  father 
suddenly  had  a  "nervous  breakdown,"  and  the  son 
was  compelled  to  remain  in  the  closest  attendance 
upon  his  father  for  the  next  year.  The  sick  man 
would  have  no  one  else  near  him  and  would  not 
listen  to  the  youth's  approaching  the  business.  The 
father  better,  the  son  felt  the  real  need  of  a  change 
and  went  away  for  six  months;  he  returned,  and 
again  there  was  the  talk  of  his  entering  the 
business.  His  father  had  a  second  attack,  and  again 
for  a  whole  year  the  son  was  chained  to  his  father. 
He  then  again  took  some  months  rest,  and  on  his 
return  the  father  had  withdrawn  from  the  business; 
there  was  no  longer  talk  of  the  son's  doing  any- 
thing. Indeed,  any  approach  to  the  subject  seemed 
so  to  agitate  his  father  that  his  son,  fearing  another 
attack,  avoided  the  subject. 

This  brief  sketch  will  suffice  to  demonstrate  the 
dominant  part  played  by  the  father — the  patient  was 
assuredly  the  father's  thing,  no  independent  being. 
An  incident  will  show  this  dependence.  My  patient 
was  at  a  seaport  when  he  was  about  21,  awaiting  a 
ship  to  go  abroad,  when  a  friend  of  the  family  met 
him  and  invited  him  to  stop  there.  He  could  give 
no  reply,  was  extremely  embarrassed,  and  wired  to 
his  father  to  come  and  help  him.  The  father 
travelled  the  four  hours'  journey,  and  my  patient  only 
felt  completely  at  ease  when  he  met  his  father. 

Now  it  is  easy  to  see  something  unnatural  in  this 
relationship,  to  interpret  it,  following  Freud,  as  a 
repressed  homo-sexual  father-complex,  whilst  the 
phobias  could  be  explained  as  substitutes  or  deriva- 
tives of  early  repressed  sexual  curiosities ;  but  this 
interpretation  would  be  quite  insufficient. 

We  learn  that  the  boy  passed  through  a  normal 


PSYCH  ASTHENIA  ill 

schooling,  that  no  symptoms  developed  until  the 
father's  breakdown,  that  this  breakdown  was  the 
frustration  of  the  patient's  whole  ambition — to  build 
ships  and  engines,  to  invent  new  kinds.  That  was 
his  special  work  in  life.  He  knew  every  important 
ship  and  most  of  the  unimportant  ones  that  were 
afloat.  He  could  recognise  a  ship  immediately  ;  we 
often  tested  his  knowledge,  which  never  failed. 
He  would  recognise  boats  by  their  whistle  and  would 
at  once  say  the  particular  ship's  name,  when  she  was 
built,  her  tonnage,  etc.  A  fine  ship  passing  the  coast 
would  fire  him  and  rouse  him  from  his  lethargy.  He 
experienced  a  sense  of  mystery  and  wonder  in  ships, 
something  that  Wordsworth  must  have  felt  when  he 
wrote  those  sonnets : — 

' '  This  ship  was  nought  to  me  nor  I  to  her, 
Yet  I  pursued  her  with  a  lover's  look." 

"...  and  something  dark 
Of  the  old  sea,  some  reverential  fear, 
Is  with  me  at  thy  farewell,  joyous  bark." 

He  was  in  love  with  ships.  Love  of  father,  mother, 
to  be  a  husband,  etc.,  these  he  shared  with  humanity 
in  common — but  ships — that  was  the  individual  thing 
which  absorbed  such  energies  as  were  not  to  be 
devoted  to  the  common  duties  of  life.  His  father  stood 
to  him  for  power  and  ships  and  engines — through  the 
father  he  could  climb  to  his  own  pinnacle.  And  then 
comes  failure.  The  patient,  inhibited  from  following 
his  purpose,  regresses,  turns  back  and  seeks  in  his 
phantasies  the  consolations  and  the  position  which 
belong  quite  legitimately  to  childhood  but  do  not  fill 
up  the  adult  outlook. 

If  we  have  hitherto  written  of  the  unconscious  as 
something  archaic  and  crude,  we  must  now  correct 
that  by  adding  that  the  unconscious  is  also  creative 
and  constructive.  A  cross-section,  so  to  say,  of  any 
mind  at  any  given  moment  would  reveal  not  only  the 


112  WAR-SHOCK 

past  but  the  germs  of  the  future — the  potentialities 
to  become  realities  with  time.  The  psyche  never  is, 
but  is  always  becoming — changing ;  there  is  ever  an 
onward  thrust. 

Biologically  the  great  functions  of  life  are : — 

I.  Those  directed  to  the  individual  comprising 

(a)  Self-conservation  and  (b)  Growth. 

II.  Those   directed   to   the   species   comprising 

(a)  Preservation  of  the  race  and  (b)  Racial 

development  (variations). 

But  we  discover  in  human  beings  a  spiritual  life 
apart  from  and  independent  of  the  biological  prin- 
ciple. This  has  also  two  relationships.  It  is  related 
to  the  universal  spirit  as  part  of  the  world-conscious- 
ness and  it  is  related  to  the  self,  forming  the  individual 
spiritual  life.  This  desire  for  an  increasing  individual 
life  of  the  spirit  is  a  strong  dynamic  force  which  we 
may  call  idio-kinesis.  This  idio-kinesis  does  not, 
among  ordinary  normal  persons  (I  must  exclude  cer- 
tain individuals,  e.g.,  the  true  saints),  demand  full 
expression  until  the  biological  energy  of  the  individual 
has  received  or  is  receiving  its  due  satisfaction. 
Conflict  ensues — a  neurosis — when  the  ordinary 
individual  endeavours  to  satisfy  his  spiritual  life 
without  having  satisfied  his  biological  functions ; 
again,  neurosis  may  arise  from  a  thwarting  of  the 
spiritual  life  by  conflict  between  the  energy  directed 
towards  the  world-consciousness  and  the  idio-kinesis. 
Again,  since  this  latter  is  ever  undergoing  change, 
we  have  here  a  constant  source  of  conflict  within  the  self. 
Idio-kinesis  finds  its  expression  in  the  most  diverse 
ways.  In  this  patient  it  was  seeking  expression  in 
ships;  conflict  had  produced  stagnation.  The  energy 
which  should  have  found  individual  expression  [this 
idio-kinesis]  was  stayed.  Hence  his  suffering.  He 
could  marry  and  fulfil  some  common  biological  objec- 
tives of  life.  The  difficulties  were  enormous — 


PSYCHASTHENIA  113 

granted,  but  life  is  relentless.  Difficulties  must  be 
surmounted.  And  the  patient  was  gradually  learning 
this. 

Two  of  his  latest  dreams  illustrate  this  new  adapta- 
tion. 

"/  was  in  a  cargo  boat  in  the  river;  we  were 
steering  straight  into  the  ferry  and  harbour.  The 
pilot  rang  down  full  speed  astern.  I  pushed  him  out 
of  the  way  and  rang  down  full  speed  ahead,  two 
points  to  starboard.  We  went  straight  past  ferry 
and  harbour  without  an  accident." 

A  few  days  later  : — 

"  In  a  motor  car :  came  to  some  rocks  which  sprang 
up  in  front  of  me.  The  machine  broke  down.  I 
abandoned  it  and  walked,  clambering  over  the  rocks. 
It  was  tough  work.  My  object  was  a  ship.  I  got 
to  the  ship  ;  took  hold  of  the  wrench  and  signalled  to 
let  go." 

We  found  by  analysis  that  the  pilot  in  the  first 
dream  and  the  motor  in  the  second  stood  for  the 
father.  The  meaning  became  clear.  He  must  first 
sacrifice  (knock  down,  abandon)  the  father  element 
in  himself,  then  his  life's  purpose  (ship),  will  be 
directed  ahead  and  in  the  right  way  (starboard). 
There  are  difficulties  (rocks)  ahead,  but  he  will  climb 
over  them.  When  the  unconscious  of  our  patient  has 
reached  this,  when  he  has  thoroughly  learnt  that  he 
must  surrender  that  which  is  infantile  and  immature  in 
himself — the  clinging  to  the  father — that  he  must  be 
master  of  himself,  we  have  reached  a  new  view-point. 
All  his  will-power  will  be  still  required  to  make  good 
the  lesson  but  he  need  no  longer  be  the  victim  of 
unknown  impulses.  He  is  not  cured,  but  he  has 
begun  to  see  in  what  direction  the  world  might  again 
live  for  him  when  his  energy  began  to  be  directed  in 
these  new  channels ;  the  phobias  and  obsessions,  even 
those  unanalysed,  began  to  diminish  in  strength. 


114  WAR-SHOCK 

But  until  these  had  been  fully  analysed  he  would  be 
wanting  in  the  knowledge  required  to  secure  the  full- 
ness of  a  new  attitude  towards  life — there  would  be 
continual  backslidings — regressions. 

The  time  at  our  disposal  was  too  short  to  do  more 
than  get  him  to  catch  a  glimpse  of  the  promised 
land.  He  has  yet  to  climb  his  Mount  Pisgah  to 
obtain  a  full  vision. 

It  will  be  seen  that  in  these  cases  of  psychasthenia 
no  cures  were  effected ;  the  patients  could  not  remain 
long  enough  under  treatment  for  this ;  a  cure  in  these 
bad  cases  requires  months.  We  had  to  be  satisfied  when 
the  acute  psychical  symptoms  abated.  These  were 
all  cases  of  pre-war  neurosis  on  a  psychopathic  basis 
— the  cases  that  remain  more  or  less  invalids — with 
ever  recurrent  breakdowns,  ending  perhaps  finally 
in  an  asylum.  If  such  illnesses  are  taken  seriously 
as  soon  as  the  symptoms  show  themselves,  psycho- 
analysis offers  them  good  hope,  I  believe  the  only 
hope,  of  fulfilling  themselves,  of  averting  the  other- 
wise almost  certain  uselessness  of  their  lives  and 
the  too  frequent  miserable  termination.  But  these 
considerations  do  not  properly  belong  to  a  book  on 
war-shock. 

DREAMS. 

Dreams  play  so  large  a  part  in  the  diagnosis  of 
the  psycho-neuroses  that  I  must  add  a  few  words  on 
the  subject,  though  it  is  one  too  large  to  treat  in  this 
little  book;  fortunately  there  is  now  an  available 
literature. 8 

8  "The  Interpretation  of  Dreams,"  by  Prof .  Sigm.  Freud. 
Translated  by  Dr.  A.  A.  Brill.  London  :  Allen  &Unwin.  1913. 

"On  Dreams,"  by  S.  Freud.  Translated  by  Dr.  M.  D. 
Eder.  London :  William  Heinemann.  1913. 

Freud's  "Theory  of  Dreams,"  by  Dr.  Ernest  Jones,  op.  cit. 

"  Analytical  Psychology,"  byC.  J.  Jung,  op.  cit. 


PSYCH  ASTHENIA  115 

Naturally  a  good  deal  of  fun  has  been  made  of 
dream-analysis,  which  is  likened  to  the  dream  inter- 
pretation of  the  ancients.  With  this  it  has  as  much 
resemblance  as  has  modern  urinary  analysis  to  the 
water  casting  of  the  Middle  Ages.  The  water  casters 
felt  that  such  an  excretion  as  the  urine  must  be  of 
some  use  in  the  diagnosis  of  disease  and  they  made 
guesses,  sometimes  true  guesses,  at  discovering  what 
the  changes  in  the  urine,  changes  in  colour  and  so 
on,  could  possibly  signify.  It  was  left  for  a  later  age 
to  invent  a  technique  for  the  examination  of  the  urine 
and  thereby  to  interpret  its  changes  in  various 
diseases.  Similarly  with  dreams,  our  predecessors 
felt  that  dreams  must  have  some  message,  and  they 
made  guesses,  sometimes  correct,  at  what  the  message 
could  be;  but  it  was  left  to  Sigmund  Freud  to  dis- 
cover a  scientific  technique  whereby  to  read  the 
riddle  of  the  dream.  Of  course  many  acute  minds  had 
before  Freud  dimly  felt  that  in  some  way  the  dream 
might  be  significant.  Bagehot''  has  a  rather  remark- 
able passage  which  is  worth  quoting.  Writing  in 
1 87 1 ,  he  says  : — 

"  That  belief  is  not  a  purely  intellectual  matter  is 
evident  from  dreams,  when  we  are  always  believing, 
but  scarcely  ever  arguing  ;  and  from  certain  forms 
of  insanity,  when  fixed  delusions  seize  upon  the 
mind  and  generate  a  firmer  belief  than  any  sane 
person  is  capable  of.  These  are,  of  course,  '  unortho- 
dox '  states  of  mind,  but  a  good  psychology  must 
explain  them,  nevertheless,  and  perhaps  it  would 
have  progressed  faster  if  it  had  been  more  ready  to 
compare  them  with  the  waking  states  of  sane  people." 

As  an  introduction  to  the  understanding  of  dreams, 
we  may  recall  the  varieties  of  symbolic  conver- 
sion in  Chapter  III.  In  the  functional  paralysis 

9  "On  the  Emotion  of  Conviction,"   by  Walter  Bagehot. 
Vol.  III.,  p.  192,  of  his  collected  Literary  Studies. 


116  WAR-SHOCK 

of  the  hysteric  one  finds  ideas,  wishes  and  mental 
processes  in  general  represented  by  their  physical 
counterparts.  So  it  is  in  dreams.  The  pictures  in 
the  dreams  stand  for,  are  symbols  of,  mental  processes. 
We  find  an  instance  of  a  horse  being  the  symbol  of 
the  man  himself  (p.  81),  of  fire  symbolising  passion, 
inability  to  move  standing  for  indecision  of  the 
mind,  and  so  on. 

It  must  be  remembered  that  in  dream-analysis  the 
symbols  to  be  interpreted  are  individual,  not  only  to 
the  person,  but  may  even  be  to  the  dream  itself. 
Thus,  fire  may  not  symbolize  the  same  idea  to 
another  person  as  it  did  to  No.  I  oo.  In  the  dream  of 
No.  78,  and  at  subsequent  stages  of  the  analysis  of 
the  same  person,  it  might  be  found  that  fire  had 
another  symbolic  value. 

The  discussion  of  typical  symbols  would  take  us 
too  far,  and  would  lead  into  the  regions  of  folk-lore, 
comparative  religion  and  mythology.  Those  inter- 
ested should  read  Jung's  ' '  Psychology  of  the  Uncon- 
scious "  J  where,  taking  the  published  phantasies  of  a 
modern  young  lady  he  has  sought  to  unravel  them 
by  a  comparison  with  the  symbolisms  of  mythology 
and  religion. 

The  value  of  the  dream  is  that  it  gives  us,  in  dis- 
guised form,  something  direct  from  the  unconscious. 
One  word  of  warning  is  necessary  ;  the  meaning  of 
the  dream  is  only  to  be  apprehended  from  its  latent 
content — that  is  to  say,  when  all  the  "  free  associa- 
tions "  to  the  component  parts  of  the  dream  have 
been  given.  From  the  dream,  as  dreamt  and  related, 
the  manifest  content,  no  meaning  is  to  be  deduced. 

It  is  to  be  remembered  that  there  are  two  motives 
for  the  symbolisation  and  the  endopsychic  censure 
is  different  in  the  two  cases.  Firstly,  to  conceal  the 

1  "The  Psychology  of  the  Unconscious."    Translated  by  Dr. 
B.  M.  Hinkle.    New  York :  Moffat,  Yard  &  Co.    1916. 


PSYCHASTHENIA  117 

dream  thoughts  from  the  dreamer's  conscious  self, 
the  censor  prevents  ideas  out  of  harmony  with  the 
dreamer's  conscious  self,  a  more  highly  developed 
self,  from  entering  into  consciousness.  Secondly,  to 
prevent  the  apprehension  of  an  idea  which  is  beyond 
the  dreamer's  experience.  In  the  first  case  the 
meaning  of  the  symbols  used  may  be  apparent  to  the 
outsider  though  not  to  the  dreamer,  since  the  main 
object  is  a  self-concealment,  whilst  the  attempt  to 
prevent  others  knowing  the  dream  thought  is  only 
secondary.  In  the  second  case  only  the  dreamer 
himself  can  really  furnish  the  clues  to  his  symbols ; 
though  it  has  an  apparent  rendering  in  universal 
terms  it  has  a  quite  particular  application.  The 
dream  here  deals  with  the  future  and  present,  using 
the  past  experiences  because  they  are  the  only 
means  of  comparison  which  the  dreamer  has.  The 
motor-car  dream  (p.  113)  is  such  a  dream,  showing 
what  Jung  calls  the  prospective  tendency  of  the  un- 
conscious. 


CHAPTER  VI 
DIAGNOSIS 

THE  soldier  is  not  immune  from  the  nervous  diseases 
of  the  civilian  ;  syphilis  of  the  central  nervous  system 
is  found  among  men  in  the  fighting  line,  as  are  tumours 
of  that  system,  disseminated  sclerosis,  epilepsy  and 
so  on.  The  diagnosis  among  soldiers  of  these  diseases 
from  the  psycho-neuroses  does  not  present  any  new 
features. 

The  differential  diagnosis  of  epileptic  from  hys- 
terical fits  is  of  medico-military  importance  and  at 
times  difficult ;  we  may  not  see  the  soldier  in  a  fit  and 
may  have  to  rely  upon  the  description  of  the  attack 
given  by  himself  or  his  comrades.  There  is  hardly  any 
feature  in  the  epileptic  attack  which  may  not  occur 
in  a  hysterical  attack ;  biting  the  tongue,  the  empty- 
ing of  the  bladder  or  of  the  rectum  may  be  present 
in  hysteria.  In  the  chronic  epileptic,  an  unlikely 
person  to  be  found  at  the  front,  the  well-known 
stigmata  of  the  epileptic  character,  such  as  limitation 
of  the  field  of  presentation,  retardation  of  all  response 
to  stimuli,  stereotypy  and  poverty  of  speech,  moodi- 
ness,  egocentricity,  exuberant  emotion,  irritability, 
suffice  to  make  the  diagnosis  easy. 

The  question  of  epileptic  or  hysterical  fits  may  be 
sometimes  settled  by  a  psycho-analytic  diagnosis. 
The  word-association  test,  which  Ernest  Jones l  has 

l  Op.  dt.,  p.  210. 

118 


DIAGNOSIS  119 

likened  to  the  differential  blood  count,  may  be  often 
useful  in  this  examination.  Reliance  is  not  to  be 
placed  so  much  upon  critical  words  as  upon  the 
interpretation  of  the  results.  The  experiment  is  very 
easily  carried  out,  but  this  interpretation,  like  that  of 
every  other  psychological  test,  requires  judgment 
and  experience.  Jung 2  gives  the  following  reactions 
as  characteristic  of  epileptics : — 

(a)  Explanations  of  an  extremely  awkward 
and  detached  character  are  given  by  way 
of  confirmation  and  completion  of  the  re- 
actions. The  stimulus-word  is  frequently 
repeated  in  the  reaction. 

(V)  The  outer  form  of  the  reaction  is  neither 
stereotyped  nor  limited  except  in  regard  to 
its  egocentric  formation,  which  occurs  with 
peculiar  frequency  (31  per  cent.). 
(c)  The  emotional  references  are  frequent,  they 
are  almost  undisguised  (religion,  moralising, 
etc). 

(cf)  The  reaction-times  show  their  most  extreme 
variations  only  after  the  critical  reactions. 
The  abnormally  delayed  times  are  not  found 
at  peculiarly  difficult  words  but  at  places 
which  are  determined  by  the  preservation 
of  an  emotional  tone. 

In  the  following  case  the  diagnosis  of  hysteria  was 
made  on  the  result  of  a  word-test  (200  words),  which 
disclosed  nothing  characteristic  of  epilepsy,  and  by 
the  fortunate  chance  that  two  recent  dreams  were 
remembered  and  at  our  disposal. 

No.  75,  a  garrison  soldier,  aged  21,  felt  giddy 
whilst  sitting  on  a  wheelbarrow,  screamed  out  and 
fell  to  the  ground  in  a  fit.  He  felt  sick  afterwards 
but  did  not  vomit.  Two  days  later  he  passed  his 

2  "Studies  in  Word- Association.''  Op.  cit.  Chapter  III. 
"  Analysis  of  the  Associations  of  an  Epileptic,"  by  C.  G-.  Jung. 


120  WAR-SHOCK 

water  whilst  sleeping  on  his  bed  in  the  afternoon ;  he 
awoke  with  a  violent  headache,  Later  that  evening 
whilst  standing  he  had  another  "fit"  and  fell.  He 
did  not  pass  water  but  awoke  with  a  burning  head. 
He  was  carried  to  his  bed  by  some  of  his  companions. 
He  had  not  hurt  himself  in  the  fall.  There  was  no 
injury  to  the  tongue.  A  witness  who  had  inserted  a 
wedge  into  the  patient's  mouth,  but  whose  evidence 
of  the  attack  was  confused  and  unreliable,  said  there 
was  blood-stained  froth  at  the  mouth.  The  patient 
stated  that  he  had  had  "  fainting  fits  "  between  the 
ages  of  9  and  1 5  ;  in  one  fit  he  is  said  to  have  bitten 
his  tongue;  he  had  been  excused  school-attendance 
on  account  of  these  fits.  He  remembered  wetting 
the  bed  sometimes  up  to  his  eighth  or  ninth  year. 
The  patient  was  admitted  to  hospital,  and  I  saw  him 
the  day  after  the  second  attack  when  he  still  com- 
plained of  headache. 

He  was  a  driver  engaged  in  garrison  duty  ;  the 
day  after  the  first  fit  he  was  afraid  to  take  out  the 
horses ;  he  had  a  vision  :  "  the  horses  falling  on  the 
hill  and  the  waggon  running  into  them."  He  had  not 
previously  suffered  from  fears  of  any  kind.  He 
took  the  horses  out  but  with  great  qualms  ;  there 
was  no  accident.  The  night  before  the  first  fit  he 
had  a  dream  :  "  Our  stables  had  been  turned  into  a 
big  hospital  where  I  was." 

The  night  before  the  second  fit  (i.e.,  after  having 
taken  out  the  horses)  he  dreamt :  "  That  the  stable 
was  built  differently  ;  that  it  was  now  the  ward  of  a 
hospital ;  we  had  18  men  there  :  I  saw  all  the  beds 
in  the  sfables,  and  I  was  lying  in  one  of  the  beds 
with  clean  sheets." 

Analysis  :  There  are  only  four  men  now  in  the 
detachment,  which  means  that  each  man  has  to  be  on 
guard  every  other  night  in  addition  to  the  day  duties. 
(Guard  from  6  p.m.  to  midnight,  or  midnight  to  6  a.m.) 


DIAGNOSIS  121 

He  has  felt  the  want  of  sleep  through  the  many  guards 
he  has  to  do.  One  of  his  chums  has  had  appendix 
trouble  and  has  been  sent  home ;  another  is  in 
hospital  with  enteric  fever.  Just  before  the  fit  he 
had  been  boasting  that  he  was  the  only  one  who  had 

never  been  ill.     He  had  been  in  M 15  months  ; 

he  liked  it  at  first,  but  the  routine  work  has  become 
very  dull,  and  he  has  nothing  to  do  in  his  spare  time. 
He  would  like  to  get  to  the  front,  but  there  was  no 
chance ;  thought  he  deserved  a  change  and  to  be 
sent  home.  He  was  engaged  before  he  left,  but  he 
heard  recently  that  the  young  lady  had  broken  off 
the  engagement. 

Both  dreams  express  the  same  unconscious  wish- 
fulfilment.  He  will  never  get  away  from  M 

unless  he  is  ill ;  the  stables  are  thus  conveniently 
turned  into  a  hospital  ward  and  he  is  in  hospital. 
One  chum  has  already  gone  home  and  the  other  is 
going  (all  enterics  being  ultimately  sent  to  England). 
Boasting  about  something  is  a  not  uncommon  form 
of  an  unconscious  wish  for  the  opposite.  The  fear 
about  an  accident  with  the  horses  is  a  (repressed) 
wish  not  to  have  the  horses  to  take  out.  Meantime 
he  conscientiously  carries  on  his  work.  The  conflict 
between  the  conscious  and  unconscious  trends  ends  in 
the  hysterical  attack  with  fulfilment  of  the  uncon- 
scious wish — for  he  is  ill  and  sent  into  hospital. 

The  analysis  was  not  pursued  further,  so  that  the 
meaning  of  the  childhood's  fainting  attacks  cannot 
be  given.  It  is  significant  that  he  was  a  "  bed 
wetter"  till  rather  late  in  childhood;  the  emptying 
of  the  bladder  after  the  first  fit  is  probably  connected 
with  the  renewal  of  certain  childhood's  conflicts.  The 
results  of  the  analysis  of  the  dreams  undertaken 
entirely  for  diagnosis,  not  for  therapeutic  purposes, 
were  of  course  not  communicated  to  the  patient. 

In  the  diagnosis  of  functional  disease,  even  where 


122  WAR-SHOCK 

it  seems  self-evident,  complete  and  systematic  exami- 
nation is  of  course  to  be  made.  The  presence  of 
organic  affections,  in  addition  to  the  functional  one, 
may  be  revealed,  or  some  further  stigmata  may  be 
discovered.  An  interesting  observation  of  the  former 
condition  is  described  by  Purves  Stewart 3  in  a  soldier 
with  wrist-drop  of  the  left  hand  due  to  a  shrapnel 
bullet,  whose  track  had  crossed  the  musculo-spiral 
groove.  There  was,  however,  complete  anaesthesia 
of  the  left  upper  limb  from  the  acromion  downwards  ; 
an  anaesthesia,  therefore,  not  corresponding  with  the 
distribution  of  the  injured  nerve. 

In  mutism  and  deafness  the  symptoms  seem  obvious, 
but  without  systematic  examination  malingering  is  not 
excluded  and  the  analgesia  sometimes  co-existing  with 
mutism  and  deafness,  such  as  described  on  p.  37, 
would  be  missed.  In  mutism  the  patient  should  be 
examined  to  see  whether  he  can  whistle,  laugh, 
cough,  sigh ;  mutism  is  sometimes  complete ;  a 
good  test  for  the  cough  is  to  strip  him  as  for 
examination  of  a  hernia,  asking  the  patient  to  cough  ; 
this  routine  examination,  which  all  soldiers  have 
gone  through,  may  take  him  off  his  guard.  The 
patients  can  express  themselves  well  in  writing, 
unlike  ordinary  aphasics.  The  laryngoscope  may 
show  adductor  paralysis.  The  faradic  current  should 
not  be  used  in  hysterical  mutism  of  soldiers,  useful 
though  it  is  in  the  common  functional  aphonia  of 
girls  and  others.  In  functional  deafness  and  ambly- 
opia  the  services  of  the  specialist,  if  available,  should 
be  requisitioned  to  make  a  report  upon  the  state  of 
the  special  senses — not  necessarily  a  diagnosis  of  the 
patient's  condition.4  An  older  generation  of  clinicians 

3  Op.  tit.  (4th  Edition),  p.  61. 

4  In  Malta  I  was  fortunate  enough  to  have  the  opinion  of 
Col.  Purves  Stewart,  A. M.S.,  for  most  of  the  general  cases,  and 
of  Capt.  A.  D.  Griffith.  R. A.M.C.,  aa  well  for  the  eye  cases. 


DIAGNOSIS  123 

called  these  amblyopias  anaesthesia  of  the  retina;  it  is 
not  a  bad  term  as  a  clinical  description,  although  the 
stimuli  are  really  conveyed  to  the  brain,  just  as  they 
are  in  anaesthesia  of  the  skin.  The  ophthalmoscopic 
examination  is  negative  ;  the  patient  is  not  betrayed 
by  any  of  the  tests  which  reveal  the  malingerer. 
Convergence  may  be  absent  and  the  examination  of 
the  visual  fields  may  show  the  characteristic  stigmata 
of  hysteria.  There  is  a  concentric  contraction  of  the 
visual  field  (see  pp.  34,  35)  with  alterations  in  the 
colour  fields. 

The  examination  of  hysterical  paralysis  shows : — 

(1)  The  anaesthesia  corresponds  to  no  anatomical 
nerve-distribution.     It  is  regional,  not  anatomical, 
in  its  distribution.     As  we  have  seen  in  Chapter  II, 
a  complete  hemianalgesia  is  common,  and  this,  unless 
there  be  special  cause  to  the  contrary,  is  on  the  left 
side  in  right-handed  people  and  vice  versa. 

Sometimes  the  patient,  though  he  says  he  is  unable 
to  feel  a  pin-prick,  can  locate  it  on  or  near  to  the 
place  pricked  with  the  normal  hand.  The  joint  sense 
may  be  impaired  and  astereognosis  be  present  with 
this  anaesthesia;  the  yes-no  test  is  sometimes  positive. 
That  is,  the  patient  answers  "no"  when  pricked  in  the 
anaesthetic  area  without  noticing  the  contradiction, 
when  asked  to  say  "yes"  when  he  feels  the  prick, 
"  no  "  when  he  does  not  feel  it. 

(2)  As  recovery  sets  in  the  anaesthesia  fades  away 
gradually  towards  the  periphery  ; 5  one  can  sometimes, 
mark   its   progress   from  day  to  day,  or  sometimes 
under  suggestion,  it  disappears  with  absolute  sudden- 
ness.  Thus,  to  a  soldier  with  a  complete  left  hemianal- 
gesia of  unknown  duration  it  was  suggested  under 
hypnosis  that  he  could  now  feel  the  prick  of  the  pin 
on   his  arm,  and  he  did.     It  was  then  said:  "You 
can  feel  everything  all  over  the  body."     Sensation 

5  See  the  illustrations  in  Pnrves  Stewart,  op.  cit.,  p.  394-5. 


124  WAR-SHOCK 

became   at   once  normal  and  so  remained  after  he 
was  awake. 

(3)  There  may  be  impairment  of  joint  sense  and 
astereognosis  due  to  the  anaesthesia. 

(4)  The  gait  is  often  typical  in  hysterical  para- 
plegics; thepatient  shuffling  along,  sometimes  sup- 
porting himself  and  falling  rather  softly  if  all  support 
is  taken  away. 

(5)  The  reflexes  may  be  sometimes  exaggerated  in 
functional  as  they  often  are  in  organic  diseases,  but  they 
are  never  absent  permanently  in  functional  disease. 

(6)  The  paralysis,  like  the  anaesthesia,  follows,  as 
a  rule,  no  anatomical  rule ;  movements  as  a  whole 
are  affected. 

(7)  The  muscles  respond  to  faradism  in  hysterical 
palsies  ;  reaction  of  degeneration  is  absent. 

The  use  of  finger  prints  has  been  suggested  in 
the  diagnosis  of  functional  from  organic  diseases  of 
the  upper  limbs.  It  is  said  that  when  the  finger 
prints  of  the  two  hands  are  compared  there  will  be 
found  an  alteration  in  the  finger  prints  of  the  injured 
side  in  injuries,  more  especially,  of  the  median  and 
ulnar  nerves,  whilst  no  changes  are  found,  or  but 
rarely,  in  functional  disease.6 

The  diagnosis  of  the  psycho-neuroses  must  not  be 
allowed  to  rest  upon  negative  evidence  ;  it  does  not 
suffice  to  diagnose  a  hysterical  paralysis  by  a  process 
of  exclusion.  Positive  evidence  must  be  obtained  by 
a  psychological  examination  which  should,  at  the 
same  time,  discover  the  mechanism  and  pathology  of 
the  symptoms. 

MALINGERING. 

To  confuse  functional  disease,  war-shock,  with 
malingering  is  no  more  excusable  than  would  be  the 
mistaking  of  an  innocent  tumour  for  a  malignant 

6  Cestan,  Descornps  and  Euziere.    La  Presse  Medicate,  1916, 
June  8,  p.  261. 


DIAGNOSIS  125 

tumour.  We  are  all,  physicians  and  surgeons,  liable 
to  error,  but  though  the  sufferers  may  pardon  our 
mistakes  and  we  may  excuse  them  in  others,  we 
must  never  condone  our  own  mistakes  in  diagnosis. 

The  differentiation  between  a  psycho-neurosis  and 
malingering  is,  in  principle,  psychological.  In  malin- 
gering the  motive  is  conscious,  the  patient  consciously 
pretends  to  suffer  from  some  symptom ;  in  functional 
disease  the  motive  is  unconscious ;  the  symptom 
develops  in  obedience  to  motives,  desires,  causes,  of 
which  the  patient's  consciousness  knows  nothing. 

Simple  cases  of  malingering  are  recognised  by 
simple  psychological  observation ;  one  infers  at  once 
from  the  patient's  general  demeanour,  from  his  story 
and  so  on,  that  he  is  shamming.  More  refined 
malingering,  especially  where  there  has  been  some 
original  trauma,  requires  more  complete  physical  and 
psychical  examination.  In  this,  as  in  every  other 
branch  of  medicine,  reliance  should  not  be  made  upon 
some  "infallible"  test,  say  the  electric  battery 
applied  to  the  seat  of  pain,  but  upon  a  balancing 
of  many  signs  and  symptoms  and  the  observer  should 
try  to  keep  himself  as  unbiassed  as  possible.  A  good 
beginning  is  for  the  observer  to  remember  that  he  is 
biassed  in  one  direction  or  other,  and  to  try  and 
discover,  if  possible,  his  particular  bias.  My  own 
experience  in  the  army  has  been  almost  entirely 
amid  the  sick  and  wounded ;  among  these  patients  I 
can  confirm  the  statements  of  Myers 7  and  others  that 
malingering  is  most  rare.  The  regimental  M.O.  may, 
of  course,  have  a  different  story  to  tell.  A  complete 
physical  examination  of  every  patient,  even  when 
malingering  is  strongly  suspected,  is  the  first  important 
step  in  diagnosis.  (This  remark  does  not  apply  so 
rigidly  to  the  regimental  doctor  to  whom  the  idiosyn- 
crasies of  the  men  will  be  known.)  Disturbances  of 
7  Loc.  cit.,  p.  608. 


126  WAR-SHOCK 

sensation,  the  peculiarity  of  gait,  are  important ;  the 
malingerer's  gait,  however  skilful,  does  not  corre- 
spond to  the  peculiar  shuffle  of  the  hysteric.  All 
text-books  on  eye-diseases  give  tests  for  pretended 
blindness. 

In  hysterical  deafness  the  patient  has  often  the 
"woolly  "  appearance  of  the  organically  deaf,  which 
the  shammer  does  not  show.  The  beginning  of  a 
reply  to  a  question  by  movements  of  the  larynx,  lips 
and  mouth  will  be  often  noticed  in  the  shammer,  who 
will,  on  cross-examination,  indignantly  deny  having 
made  them ;  the  hysterical  patient's  attitude  is  very 
different,  to  him  it  is  not  an  accusation. 

Dundas  Grant8  points  out  that  patients  with 
psychical  deafness  sometimes  acquire  lip  -  reading 
with  great  rapidity,  which  he  regards  as  "unquestion- 
able evidence  of  a  high  degree  of  deafness."  Grant 
suggests  the  following  test : 

"  It  is  the  dilatation  of  the  pupil  which  follows  the 
sudden  blowing  of  a  whistle  without  the  patient  being 
aware  of  it ;  in  several  cases  of  labyrinthine  deafness 
this  was  absent,  but  in  others  which  seemed  to  be  of 
psychical  origin  the  reflex  was  present,  although  the 
deafness  was  absolute  or  nearly  so.  In  the  dullness 
of  hearing  due  to  exhaustion,  which  shows  the  tuning- 
fork  indications  of  nerve-deafness,  there  is  usually 
preservation  of  hearing  for  the  highest  pitched  tones. 
Labyrinthine  and  psychical  deafness  may  be 
combined,  but  the  labyrinthine  factor  is  generally 
unilateral." 

"  Exaggeration"  of  symptoms  or  undue  sensibility 
to  pain  is  not  malingering ;  one  man  with  a  functional 
paraplegia  will  be  cheerful  and  try  his  utmost  to  get 
about;  another  with  the  same  affection  will  be  de- 
pressed, complain  that  he  is  done  for  life,  cannot 

8  Discussion  on  Shell-shock.    Proceedings  of  Royal  Society 
Medicine,  loc.  cit.,  p.  xxxviii. 


DIAGNOSIS  127 

walk  a  step.  These  are  temperamental  differences 
which  we  all  allow  for  in  organic  diseases  and  must 
be  prepared  to  find  in  functional  diseases  likewise. 
A  patient's  desire  to  make  the  most  of  a  symptom 
neither  excludes  functional  nor  organic  disease. 

Functional  disease  may  exist  along  with  malinger- 
ing, just  as  we  have  seen  that  organic  and  functional 
disease  are  not  mutually  exclusive. 

In  all  serious  cases  a  psychological  examination 
should  be  made.  The  discovery  of  the  unconscious 
motive  for  the  symptom,  its  psychological  expla- 
nation, diagnoses  the  condition.  Though  psycho- 
therapy is  not  admissible  as  a  therapeutic  test,  the  cure 
of  the  symptom  by  psychotherapeutic  measures  will 
confirm  the  diagnosis  arrived  at  before  treatment. 

The  differential  diagnosis  of  the  psycho-neuroses 
from  one  another  is  based  upon  the  psychological 
principles  set  forth  in  the  earlier  chapters. 


CHAPTER   VII 
TREATMENT 

THE  results  of  psychotherapy  in  cases  of  war-shock 
establish  its  claim  to  be  the  chief  method  of  treat- 
ment. The  following  table  summarises  the  results 
in  the  first  hundred  unselected  cases  treated: — 

Method  of  Treatment.       Cured.       Improved.       No  change.       Total. 

Suggestion  under 

hypnotism  ...  70  ...  7  ...  2  ...  79 

Suggestion  with- 
out hypnotism  3  ...  2  ...  —  ...  5 

Suggestion  under 
anaesthetic  ...  6  ...  —  ...  —  ...  6 

Psycho-analysis...  1      ...        4        ...       —       ...        5 

Other  methods  ...          —      ...        1        ...        1        ...        2 

Diagnosis  -with- 
out treatment  —  ...  —  ...  [3]  ...  3 

80~  14  6  [3]         10? 

By  a  cure  we  mean  complete  cessation  of  all  the 
symptoms ;  a  certain  number  of  these  patients  when 
cured  were  sent  into  the  convalescent  camps  at  Malta 
and  were  then  drafted  back  to  the  Front.  The 
majority  went  back  to  England  at  varying  intervals 
after  their  recovery,  the  intervals  varying  with  the 
military-medical  requirements.  I  often  tried  to 
ascertain  the  subsequent  fortunes  of  these  patients, 
but  have  only  succeeded  in  a  few  instances. 

By  improvement  is  meant  relief  of  some  symptoms 
only ;  thus,  the  paraplegic,  No.  9,  was  able  to  walk 

128 


TREATMENT  129 

normally,  the  analgesia  had  gone,  but  as  the  rigidity 
of  the  back  remained  when  he  left  us  we  had  not 
reckoned  it  a  cure.  (A  wider  claim  for  this  parti- 
cular case  is  made  by  Purves  Stewart,1  who  writes, 
"  under  treatment  by  suggestion  the  weakness  of  the 
legs  rapidly  disappeared,  the  'stocking'  anaesthesia 
cleared  up  and  the  patient  became  able  to  walk 
normally.") 

In  the  cases  where  the  prominent  symptoms  are 
psychical  we  have  reckoned  it  an  improvement  when 
sleep  returned,  the  patient  could  control  himself  and 
concentrate  his  attention. 

The  cure  in  the  great  majority  of  cases  took  place 
very  rapidly  ;  e.g.,  mutism  recovered  in  the  course  of 
a  few  minutes  ;  many  cases  of  palsy  or  complete 
paralysis  (hemiplegia)  recovered  in  less  than  24  hours. 
Cases  frequently  called  neurasthenia,  but  which  I  have 
here  included  among  the  anxiety -neuroses,  were  the 
slowest  in  recovering,  but  in  many  of  these  cases  the 
main  symptoms,  such  as  the  exhaustion,  insomnia, 
dread,  headache,  tremors,  disappeared  in  a  week. 
No  case  was  under  treatment  for  more  than  four 
weeks  ;  very  few  remained  under  treatment  for  more 
than  two  weeks. 

Of  secondary  importance  is  treatment  by  what 
Dr.  Stansfield  calls  "rational  lines,"2 — "absolute 
rest  and  quietness,  with  all  the  sleep  possible,  pre- 
ferably with  agreeable  surroundings  in  the  country ; 
a  nourishing,  easily  assimilated  food,  and  the  like," 
or  by  what  Major  Mott3  denotes  as  "only  common 
sense  and  interest  in  the  welfare  and  amusement  of 
these  neurotic  patients." 

Hydrotherapy,    electrotherapy,    massage    are,    in 

1  Loc.  cit.,  p.  516. 

2  Proceedings  of  Royal  Society.     Discussion  on  Shell-shock 
Loc.  cit.,  p.  32. 

3  The  Lancet,  March  llth,  1916.,  p.  553. 


130  WAR-SHOCK 

my  opinion,  of  tertiary  importance  ;  I  agree  with 
Dr.  Leonard  Guthrie,*  who  says,  ' '  I  believe  that  all 
forms  of  treatment  involve  the  employment  of  either 
suggestion  and  persuasion  or  of  some  novel  and 
unexpected  emotional  or  physical  shock,"  with  the 
exception  of  treatment  «by  psycho-analysis,  which 
does  not  involve  anything  of  this  kind. 

We,  of  course,  want  the  best  surroundings  we  can 
get  for  our  patients,  just  as  the  surgeon  would  desire 
them  in  the  case  of  a  fractured  bone  but,  just  as  he 
employs  something  specific  to  the  bone  injury,  so  we 
should  employ  something  specific  to  the  mental 
injury. 

"Rational  lines  of  treatment,"  "common-sense," 
demand  the  treatment  which  most  rapidly  relieves 
the  patient  and  sends  him  back  to  the  army  most 
quickly. 

Suggestion  under  hypnotism,  especially  when  the 
suggestions  are  based  on  the  knowledge  of  the 
particular  psychological  mechanism  which  has  pro- 
duced the  symptom,  is,  from  this  rational  point  of 
view,  the  method  of  election  for  cases  of  war-shock 
in  the  soldier. 

The  soldier  is  peculiarly  susceptible  to  suggestion ; 
the  whole  training  and  discipline  make  him  respond 
to  the  authority  of  the  Medical  Officer. 

It  is  because  war-shock  differs  in  the  respects 
already  pointed  out  from  the  psycho-neuroses  such  as 
we  see  in  civilian  practice,  and  of  which  the  war 
also  furnishes  instances — I  have  discussed  several 
cases  in  this  book — that  the  results  of  suggestion  are 
so  much  more  favourable  than  are  usually  obtained, 
at  any  rate  in  my  own  knowledge,  in  civil  practice. 

Babinski 5  distinguishes  functional  cases  that  dis- 
appear rapidly  under  psychotherapy  from  those  in 

4  Proceedings,  Royal  Society,  loc.  cit.,  p.  41. 

5  Revue  Neurologique,  1916.    Nos.  4—5,  p.  52. 


TREATMENT  131 

whom  this  method  seems  to  have  no  effect,  His 
view  is  endorsed  by  Grasset,  Claude,  and  others.  A 
better  division  is  into  the  following  group : — 

A.  War-shock  ;  cases  of  psycho-neurosis  without 
previous  history,  family  or  personal. 

B.  Non  war-shock  ;  psycho-neurosis  with  a 
previous  history. 

There  were,  as  already  stated,  in  the  one  hundred 
cases,  70  of  Group  A.  and  30  of  Group  B, 

The  following  table  shows  the  comparative  results 
of  the  treatment  of  the  two  groups ;  both  total  cases 
and  in  percentages  : — 

RESULT  OF   TREATMENT  OF    IOO   CASES. 

War-shock.  Non  War-shock. 

62  per  cent. 


Cured  62  . 
Improved      ...       6  . 
No  change    ...    — 
No  treatment, 
diagnosis  only  2  .. 

,.  91*5  per  cent. 
..    8-5 

...     18 
...      8 
...       3 

...       1 

...     62 
...     27' 
...     10 

70         100  30          100 

Of  the  war-shock  cases  68  were  treated,  and  of  the 
non  war-shock,  29.  As  might  be  expected  the  former 
give  better  results,  91  "5  per  cent :  62  per  cent. 

In  no  case  of  the  former  was  the  condition  un- 
changed, all  three  total  failures  (10*4  per  cent.)  being 
among  the  non  war-shock  cases.  No  results  of  any 
value  are  obtained  by  a  comparison  of  the  results 
obtained  by  the  different  methods  of  psychotherapy 
that  were  employed.  For  instance,  all  the  cases 
treated  by  suggestion  under  an  anaesthetic  were 
cured,  but  this  method  was  selected  for  the  deaf  and 
dumb  cases  in  whom  there  were  obvious  difficulties  in 
the  way  of  hypnotising.  It  can  be  done  by  writing, 
but  it  is  a  tedious  process  unless  one  has  an  excep- 
tionally clear  and  imposing  script. 

Again,  only  one  case  out  of  five  was  cured  by 


132  WAR-SHOCK 

psycho-analysis  but  this  method  was  only  applied 
in  non  war-shock  cases  of  great  severity  with  a 
strong  neuropathic  history  (family  and  personal). 

The  particular  psychotherapeutic  method  employed 
was  selected  as  the  most  appropriate  after  the  pre- 
liminary psychological  and  clinical  examination. 

The  objection  raised  to  treatment  by  suggestion 
under  hypnosis,  e.g.,  by  Dejerine  and  Gauckler,6  that 
one  weakens  instead  of  strengthening  the  patient's 
critical  powers,  applies,  as  I  pointed  out  in  my  Malta 
Address  (loc.  cit.,  p.  668),  and  as  Professor  Elliot 
Smith  also  observes"  to  suggestion  in  all  forms, 
whether  it  takes  the  form  of  suggestion  in  the  waking 
state,  common-sense  talks,  rest,  distraction,  electro- 
therapy, or  spontaneous  recovery. 

The  objection  has  no  validity  in  cases  of  war-shock, 
though  it  has  point  in  cases  of  profound  hysteria  or 
psychasthenia  which  come  under  notice  in  civil  life. 

Minor  advantages  of  psychotherapy  are  that  it 
requires  no  elaborate  apparatus,  no  prolonged  sojourn 
in  hospital,  and  has  no  savour  of  charlatanism  like 
the  more  popular  and  less  efficient  methods  such  as 
electrotherapy,  massage,  Weir-Mitchell  treatment. 

By  none  of  these  methods,  not  even  in  spontaneous 
recovery,  does  the  patient  learn,  although  he  may 
obtain  intellectual  apprehension,  the  real  significance 
of  his  illness,  nor  can  this  be  brought  home  by  any 
arguments  addressed  to  the  conscious  self  (such  as 
Dubois'  persuasion  method). 

Psycho-analysis,  which  was  employed  in  six  cases 
of  the  100  (in  one  case  for  diagnosis  only)  is  the  only 
method  that  enables  the  patient  to  deal  with  the 
underlying  mental  state,  and  not  merely  with  the 
symptom ;  in  psycho-analysis  the  patient  learns  for 

6  "  Les  maladies  fonctionelles  des  Psychonevroses."    Paris : 
Masson  &  Co.,  1911. 

7  Loc.  cit.,  p.  27. 


TREATMENT  133 

himself  the  real  significance  of  his  disease,  a  privilege 
only  acquired  by  a  bitter  self-realisation. 

Whilst  it  is,  in  my  opinion,  the  only  method  for 
the  radical  treatment  of  the  psycho-neuroses,  it  is 
inapplicable  and  unnecessary  for  the  treatment  of 
cases  of  war-shock,  and  for  many  of  the  psycho- 
neuroses  occurring  among  soldiers.  To  use  it  here 
is  to  employ  a  Nasmyth  hammer  to  crack  a  nut. 

The  shock  of  battle  is  not  an  every-day  affair — 
especially  such  warfare  as  this.  It  is  this  unusual 
experience,  so  utterly  foreign  to  the  normal  routine 
of  life,  that  has  bowled  the  man  out.  He  requires 
temporary  reinforcement  of  his  own  will-power,  and 
this  is  just  what  hypnotic  suggestion  supplies. 

The  practical  objection,  apart  from  the  philo- 
sophical objection,  in  the  ordinary  civilian  type 
of  psycho-neurosis  that  one  symptom  is  cured  to  be 
replaced  by  some  other  symptom,  does  not  hold  in 
war-shock  cases,  the  symptoms  when  cured  are  not, 
in  my  experience,  replaced  by  other  symptoms. 

The  results  obtained  in  Malta  may  claim  to  be  due 
purely  to  psychotherapy.  The  patients  were  two 
thousand  miles  from  Britain  and  did  not  know 
whether  they  would  be  sent  home  or  back  to  the 
Front  on  recovery.  No  bribe  was  offered  in  the 
shape  of  a  promise  to  get  the  patient  sent  to  England 
on  recovery ;  many  cases,  indeed,  owing  to  the 
military-medical  situation,  had  to  be  sent  to  the 
Convalescent  Camps  and  so  back  to  the  Front  on 
recovery,  and  this  sooner  than  was  altogether 
advisable. 

Babinski s  and  other  French  authorities  have  recog- 
nised the  value  of  psychotherapy  in  the  treatment 
of  the  war  psycho-neuroses.  Nonne9  also  speaks 

8  Loc.  tit. 

9  Nonne.  ZurtherapeutischenVerwendtmg  der  Hypnose  bei 
Fallen  von  Kriegshysterie.     Med.  Klinik,  1915,  p.  51/52. 


134  WAR-SHOCK 

of  the  exceptionally  good  effect  of  systematic  and 
exclusive  hypnosis  in  these  cases.  Out  of  63  of  his 
cases  51  were  cured,  46  by  suggestion  under  hypnosis, 
5  by  suggestion  in  the  waking  state  ;  of  the  12  cases 
uncured  10  were  refractory  to  hypnotism.  (A  very 
large  number  which  leads  me  to  believe  that  these 
were  not  cases  of  war-shock  as  denned  in  this  book.) 

GENERAL  PROCEDURE, 
It  may  be  well  to  state  exactly  what  the  procedure 

£!.•».".    a 

was. 

The  patients  were  transferred  to  the  psycho- 
neurological  department,  after  having  been  seen  by 
one  of  the  consulting  physicians  to  the  Malta  Com- 
mand and  recommended  for  treatment.  A  few  cases 
from  neighbouring  hospitals  were  treated  as  out- 
patients, of  course  with  the  sanction  of  the  C.O. 

These  patients  when  admitted  were  scattered  in 
the  various  wards,  so  as  to  avoid  a  conglomeration  of 
persons  suffering  from  nerves  with,  it  was  feared, 
disastrous  intercommunication. 

But  this  is  not  necessary  or  desirable.  The 
patients  could  not  be  prevented  meeting  and  talking 
with  one  another  in  the  grounds  or  wards,  etc. ;  in- 
deed, it  was  not  a  case  of  evil  communications  cor- 
rupting good  manners,  the  contrary  was  the  case. 
The  new  patients  were  able  to  note  the  rapid  pro- 
gress towards  recovery  of  the  older  ones. 

The  patient  underwent  a  physical  examination  in 
the  ward  after  admission.  He  then  came  to  a 
"  bunk  "  placed  at  my  disposal  by  the  O.C.  (Lt.- 
Col.  Scanlon).  This  was  a  bare,  whitewashed  room 
furnished  with  an  armchair,  "  officer's  table "  and 
wooden  chair.  The  psychological  investigation  was 
conducted  in  private.  No  one  was  allowed  into  the 
room.  The  patient  was  comfortably  seated  in  the 
chair  and  put  as  much  at  ease  as  possible.  An  ex- 


TREATMENT  135 

planation  was  given  to  him  as  to  the  nature  of  the 
proposed  enquiry  and  treatment,  and  he  was  encour- 
aged to  talk  about  himself  and  his  illness,  his  life  in 
the  army ,  and  so  on ;  any  dreams  were  taken ,  but 
nothing  more  was  done  the  first  day.  The  next  day, 
after  a  short  conversation,  when  the  procedure  of 
hypnotism  was  explained,  hypnotism  was  induced, 
and  suggestions  given  based  when  possible  on  the 
results  of  the  psychological  observation.  In  most 
cases  Liebault's  method  of  inducing  hypnotism  by 
direct  suggestion  readily  produced  drowsiness. 
Sometimes  Braid's  method  was  adopted  at  the  first 
attempt,  an  ophthalmoscopic  mirror  being  held  before 
the  patient's  eyes  for  a  few  minutes. 

As  a  rule  the  stage  of  drowsiness  was  quite  suffi- 
cient for  our  purposes  ;  but  when  further  insight  was 
desired  on  the  pathological  aspects  of  the  disease, 
and  sometimes  for  treatment,  deep  sleep  and  somnam- 
bulism were  produced. 

In  producing  hypnosis  there  was  no  necessity 
to  exclude  the  presence  of  strangers  and  the 
sitting  was  used  as  a  means  of  demonstrating  the 
production  and  phenomena  of  hypnotism  to  one's 
colleagues . 

Collective  suggestion  under  hypnotism  was  found 
also  of  practical  value.  We  could  have  four  or  five 
patients  on  ordinary  chairs  (the  room  not  holding 
more  comfortably),  and  hypnotise  them  all  (either 
singly  or  collectively),  passing  from  one  to  another 
with  the  individual  suggestions. 

This  saved  time  and  allowed  more  time  for  the 
individual  examinations.  As  a  rule  a  patient  was 
not  kept  under  hypnosis  longer  than  fifteen  or  twenty 
minutes.  After  being  awakened,  he  was  required  to 
carry  out  consciously  what  he  had  accomplished  under 
hypnosis  and  was  then  directed  to  return  to  his 
ward  and  rest  for  half  an  hour. 


136  WAR-SHOCK 

A  too  long  prolonged  hypnotism  is  exhausting  to 
most  persons  and  retards  recovery. 

The  patients  were  seen  every  day  alone ;  naturally 
with  20  to  30  patients  one  could  not  give  an  hour  to 
each  daily  ;  for  some,  10  minutes  had  to  suffice 
when  one  perhaps  gathered  some  fresh  information 
or  obtained  a  dream. 

Hypnotism  is  easily  induced  among  soldiers ;  in 
only  three  cases  of  them  did  it  altogether  fail  at  the 
first  attempt. 

The  selection  of  cases  unsuitable  for  this  procedure 
was  made  after  the  psychological  examination. 

If,  after  a  few  days  treatment,  no  improvement 
was  noticed,  hypnotism  was  given  up  and  suggestion 
in  the  waking  state  was  tried. 


HYPNOTISM    UNDER    ANESTHETIC. 

On  June  10th,  1915,  a  deaf  mute,  No.  35,  was 
admitted  into  my  ward  from  Gallipoli,  the  only 
medical  case  in  a  batch  of  wounded  soldiers.  The 
work  was  very  heavy,  the  hospital  having  been 
opened  on  the  8th  of  June,  and  I  wrote  to  the  patient 
I  would  attend  to  him  in  a  day  or  two,  and  he  would 
get  well.  It  was  not  till  three  days  later  that  we 
could  take  him  in  hand ;  enquiries  were  made  in 
writing  ;  this  was  found  a  tedious  business  (my  hand- 
writing, I  regret  to  say,  is  none  too  good),  and  hyp- 
nosis under  such  conditions  did  not  promise  to  be 
very  satisfactory,  so  recourse  was  had  to  the  well- 
known  method  of  inducing  hypnotism  under  an 
anaesthetic. 

This  method  of  inducing  hypnotism  under  an 
anaesthetic  should  be  reserved  for  cases  where 
hypnosis  is  very  difficult  ;  personally  I  should  restrict 
it  to  functional  deaf  mutism,  mutism,  or  deafness. 


TREATMENT  137 

Milligan l  advocates  this  method  not  only  in  those  cases 
but  also  in  hysterical  loss  of  memory,  palsies,  deformi- 
ties. Hypnosis  is  so  readily  induced  among  soldiers 
that  there  is  no  reason  at  all  for  submitting  these 
patients  to  the  extra  risk  of  an  anaesthetic.  Sugges- 
tion under  ordinary  hypnosis  works  quite  as  rapidly 
as  when  under  an  anaesthetic. 

Chloroform  was  given  till  light  anaesthesia  was 
obtained ;  the  patient  was  then  told  he  would  be  able 
to  hear  and  speak  when  he  woke  up.  A  mouth-gag 
and  the  tongue-forceps  were  used.  The  suggestion 
was  repeated  continuously  until  the  patient  awoke. 
The  patient  spoke  whilst  under  the  anaesthetic.  A 
gramophone  happened  to  be  playing  in  the  adjoining 
ward  ;  this  was  the  first  sound  he  heard  on  awaking ; 
the  goat-bells  outside  were  next  heard.  He  spoke 
a  little  later.  This  method  was  used  in  all  cases  of 
deaf  mutism  with  entire  success.  It  failed  in  one  case 
under  the  care  of  Lt.  Fothergill,  R.A.M.C.  This 
patient  had  been  previously  hypnotised  by  Lt. 
Fothergill  but  the  suggestion  had  not  been  successful. 

In  another  case  of  mutism,  No.  42,  hypnotism  was 
induced,  but  the  suggestion  was  unsuccessful.  The 
chloroform  method  was  not  used  because  the  patient, 
on  the  advice  of  a  doctor,  did  not  wish  it.  This 
patient  had  been  rather  harshly  treated.  It  would 
seem  that  a  surgeon  who  saw  him  was  inclined  to  regard 
it  as  a  case  of  malingering,  and  applied  the  electric 
battery  to  the  larynx,  which  made  him  feel  worse ; 
the  battery  was  used  a  second  time ;  perhaps,  rather 
naturally,  the  surgeon  somewhat  resented  the  failure 
of  the  patient  to  improve  under  a  mode  of  treatment 
which  had  been  often  successful  in  hysterical  aphonia 
among  girls.  The  patient  came  under  me  some  ten 

1  "A  Method  of  Treatment  of  Shell-shock,"  by  E.  T.  C. 
Milligan.  M.D.,  B.S.  The  British  Medical  Journal,  July  15th, 
1916.  p.  73. 


138  WAR-SHOCK 

weeks  after  he  had  been  on  the  island ;  suggestion 
under  hypnosis  failed,  but  I  began  in  the  conscious 
state  the  re-education  of  his  speech.  One  by  one, 
I  got  him  to  pronounce  the  letters  of  the  alphabet, 
by  showing  him  the  position  for  each  letter ;  he  was 
getting  successful  with  simple  consonants  and  words 
when  he  had  to  be  transferred  to  England. 

PHYSIOLOGICAL    RE-EDUCATION. 

This  process  (physiological  re-education)  is,  of 
course,  slow,  but  in  cases  of  long  standing  when 
other  therapy  fails  it  deserves  consideration. 

Re-education  is  a  method  to  fall  back  upon  in 
cases  of  paralysis  when  psychotherapeutic  methods 
fail.  Each  part  of  the  limb  must  be  separately 
educated  to  fulfil  its  function,  and  finally  co-ordina- 
tion of  the  limbs  and  body  must  be  taught. 

This  method  of  physiological  re-education  is  also 
recommended  by  Briand  and  Philippe2  in  obstinate 
cases,  who  cite  a  case  of  deaf  mutism  of  some  dura- 
tion successfully  treated  by  exercises  in  respiration, 
blowing,  whistling  and  phonation. 

SUGGESTION  WITHOUT   HYPNOSIS. 

Treatment  by  suggestion  without  hypnosis  is  of 
course  familiar  to  every  practitioner ;  the  patient  is 
encouraged  by  being  assured  that  there  is  no  physical 
injury,  that  he  will  get  better,  that  it  depends  on  his 
own  good  will.  But  it  is  not  everybody  who  can  be 
thus  helped  to  make  an  effort;  it  is  desirable  to 
adapt  the  language  to  the  patient.  There  are  some 
persons  who  resent  talk  of  this  nature  and  on  whom 
it  would  have  the  contrary  effect.  A  certain  tact  is 
required  to  discover  this  and  to  fit  the  exhortation 

2  "  L'audi-mutite  rebelle  d'origine  emotionelle."  Le  Progrce 
Medicale:  September  5th.  1916,  p.  147. 


TREATMENT  139 

to  the  patient.  Just  as  we  must  adapt  the  splint  to 
the  individual  fractured  limb,  so  we  must  adapt  our 
suggestion  to  the  individual  paralysed  mind ;  stock 
suggestions  are  no  better  than  stock  splints  for 
injured  soldiers. 

PERSUASION — RE-EDUCATION. 

These  are  terms  given  by  various  writers  to 
suggestion  without  hypnosis.  De  jerine  and  Gauckler 3 
say  that  "  it  consists  in  explaining  to  the  patient  the 
true  reasons  for  his  condition.  The  part  that  the 
physician  plays  is  to  recall,  awaken  and  direct." 

To  the  patient  this  comes  merely  as  suggestion; 
cure  comes  about,  although  the  writers  have  failed 
to  recognise  it,  exactly  in  the  same  way  as  by 
suggestion  under  hypnosis,  that  is,  by  "trans- 
ference "  to  the  physician. 

We  shall  deceive  ourselves  less  as  to  the  method 
of  a  cure  if  we  keep  to  the  original  term  "  sugges- 
tion" for  all  methods  which  depend  upon  the 
physician's  directing  and  governing  the  patient. 
Cases  where  the  treatment  is  exactly  that  described 
by  these  writers  as  persuasion  have  been  described 
(see  No.  lo,  p.  71). 

In  what  class  of  war-shock  cases  suggestion  with- 
out hypnosis  yields  quicker  results  than  with  hypnosis 
is  a  difficult  question  to  decide.  When  no  post- 
hypnotic  influence  occurs  after  the  second  or  third 
session,  I  prefer  to  use  suggestion  (persuasion,  re- 
education, etc.). 

Psycho-analysis  is  the  method  for  the  exploration 
of  the  unconscious  mind  whereby  the  energy  hitherto 
wasted  in  internal  conflict  is  made  available  for  the 
purposes  of  life. 

Whereas  any  medical  man  can  easily  master  the 
technique  of  hypnotism  and  suggestion  in  simple 
3  Op.  cit. 


140  WAR-SHOCK 

cases,  psycho-analysis  requires  a  long  apprentice- 
ship; it  cannot  be  acquired  from  books  alone.  It 
will  not  be  described  here ;  no  one  is  qualified  to 
undertake  psycho-analysis  who  has  not  submitted 
himself  to  the  discipline  of  psycho-analysis  by 
another.  Like  every  practical  art  it  must  be  learnt 
in  the  workroom.  The  study  of  the  literature, 
important  as  it  is,  cannot  replace  the  laboratory. 

SUGGESTION  AND   PSYCHO-ANALYSIS. 

This  is  the  most  fruitful  method  of  treatment  in 
war-shock.  The  general  results  of  psycho-analytic 
knowledge  are  applied  to  the  results  obtained  from 
the  psychological  examination  of  the  individual 
patient.  We  aim  at  discovering  the  psycho-patho- 
logy of  his  symptoms  (not  necessarily  of  the  whole 
mental  state).  This  knowledge  is  used  as  the 
suggestion  whilst  the  patient  is  under  hypnosis  (or 
not  hypnotised).  Many  cases  cited  give  evidence 
of  the  value  of  this  method  (see  No.  95,  p.  95).  The 
difficulty  in  suggestion  is  to  know  what  to  suggest. 
When  you  have  discovered  the  patient's  complex 
this  difficulty  is  overcome.  The  procedure  is,  of 
course,  not  new  ;  I  have  practised  it  with  a  col- 
league in  London  for  some  time  before  the  war,  he 
sending  me  the  patients  for  psycho-analytic  examina- 
tion. The  discovery  of  what  lay  at  the  roots  of  the 
symptom  was  imparted  to  my  colleague  who  used 
the  information  in  suggestion  under  hypnosis. 

Distraction.  Sufficient  has  been  said  on  this  subject 
in  the  section  on  the  soldiers'  heart. 

Rest.  In  a  few  cases,  but  in  very  few  cases,  rest, 
feeding,  Weir-Mitchell  treatment  may  be  necessary. 
The  type  of  case  requiring  this  is  a  soldier  who  has 
had  several  mental  breakdowns  before  the  war,  who 
is  suffering  from  psycho-neurotic  symptoms  with  acute 
psychical  symptoms,  such  as  incoherence,  insomnia 


TREATMENT  141 

want  of  concentration,  with  accompanying  wasting 
and  anaemia.  I  have  cited  a  case  where  the  psycho- 
neurosis  only  developed  after  enforced  rest  in  hos- 
pital and  this  should  serve  as  a  hint  how  dangerous 
this  treatment  may  be.  It  is  most  unsuitable  for 
cases  of  war-shock  among  soldiers — it  prolongs  their 
illness  and  may  sow  the  seeds  of  a  more  permanent 
psycho-neurosis.  War-shock  requires  vigorous  treat- 
ment and  return  to  active  life  as  soon  as  possible. 
The  reckless  way  in  which  a  rest  cure  and  over-feeding 
are  ordered  indiscriminately  for  all  persons  suffering 
from  any  form  of  psycho-neurosis  reveals  lamentable 
ignorance.  It  is  the  very  reverse  of  rational  treat- 
ment. It  is  as  if  one  were  to  prescribe  digitalis  off 
hand  for  every  patient  who  complains  of  a  pain  in 
the  left  side  of  the  chest,  or  opium  for  everyone  who 
has  abdominal  symptoms.  A  rest  cure  is  not  merely 
negative  or  even  symptomatic  treatment.  To  a  not 
inconsiderable  number  of  these  patients  it  is  some- 
thing positive  and  positively  dangerous.  In  some 
obsessional  cases  a  rest  cure  delivers  the  unfortunate 
victim  over  to  an  unceasing  conflict  with  his  fears 
without  the  chance  of  any  distraction.  A  rest  cure  is 
a  sad  misreading  of  Hilton's  advocacy  of  physio- 
logical rest.  To  many  hysterics  a  rest  cure  affords 
the  ideal  conditions  for  retirement  from  life's  duties 
and  strengthens  their  motives  for  remaining  ill. 

Drugs  are  used,  of  course,  in  the  treatment  of 
different  physical  ills  in  the  same  way  as  the  patient's 
wounds  receive  attention. 

Stimulants  are  valueless  and  as  the  soldiers  had 
not  to  buy  their  own  drugs  any  value  that  Sanatogen 
or  its  British  counterparts  might  have  are  discounted. 
This  expensive  form  of  quackery  is  useless  in  the 
Army. 

The  only  hypnotic,  used  very  occasionally,  was  one 
of  the  bromide  salts.  Occasionally  hypnotism  was 


142  WAR-SHOCK 

used  to  put  patients  to  sleep ;  for  wounded  patients 
in  a  restless,  excited  condition  it  was  often  useful. 
Hypnotism  had  also  a  useful  field  in  the  first  and 
second  dressings  of  very  painful  wounds. 

AFTER   TREATMENT. 

Cases  with  a  pre-war  history  of  psycho-neurosis  are, 
in  general,  useless  for  the  fighting  ranks ;  they  can 
find  plenty  of  other  useful  occupations  in  the  Army  or 
civilian  life. 

The  war-shock  case  is  as  suitable  for  return  to  the 
field  as  the  soldier  who  has  recovered  from  severe 
wounds. 

After  cure  of  the  symptoms  the  patient  should  not 
be  sent  forthwith  to  the  Front.  Six  weeks  to  three 
months  after-cure  is  required,  the  first  part  of  which 
time  I  cannot  but  think  might  be  spent  on  furlough 
with  his  family ;  the  latter  part  in  one  of  the  con- 
valescent camps  where  the  soldier  will  be  gradually 
retrained. 

Gaupp4  found  that  in  his  hysteric  patients  "the 
symptoms  returned  and  became  intensified  as  soon  as 
the  words  '  fit  for  duty '  are  said."  It  is  not  my 
experience ;  I  imagine  that  Gaupp's  cases  had  not 
been  cured  in  the  sense  in  which  the  word  is  used  in 
this  book.  As  I  have  already  said,  many  of  my 
patients  went  to  the  Convalescent  Camp  in  Malta 
with  the  knowledge  that  this  meant  returning  to  the 
Front  (which  they  did).  Ten  days  at  the  least  always 
elapsed  from  the  time  they  were  marked  up  fit  for 
the  Convalescent  Camp  till  the  time  they  went.  In 
no  case  was  there  a  relapse;  on  the  contrary,  the 
knowledge  that  their  medical  officer  seemed  to  think 
them  cured  served  to  put  them  in  better  spirits.5  In 

4  I  quote  from  Prof.  Elliot  Smith's  summary  of  Gaupp's 
paper;  loc.  cit.,  p.  17,  18. 

5  These  men,  of  course,  expressed  no  wish  to  go  back  to  the 
Front  and  all  would  have  preferred  to  be  sent  home. 


TREATMENT  143 

one  case  (No.  1)  after  a  relapse  in  the  sense  that 
irritability  had  come  on,  the  patient  begged  me  to 
send  him  to  the  Camp  as  soon  as  he  got  better,  which 
I  did  with  the  happiest  results.  Another  patient 
(No.  32)  also  got  moody  by  being  unavoidably 
detained  in  hospital  after  he  was  well. 

The  Uncured.  If  properly  treated  the  number  of 
uncured  cases  will  be  small ;  my  figures  give  3  per 
cent.,  but  this  number  could  be  reduced.  It  includes 
No.  62,  a  case  of  enuresis  which  had  existed  from 
childhood,  and  was  not  in  itself  a  disease  totally 
disabling  the  patient  either  from  service  in  the  Army 
or  civil  occupation.  (He  had  always  earned  a  living 
before  the  war.)  The  other  case  of  mutism  will 
certainly  recover  his  speech — probably  he  recovered 
it  on  reaching  England.  The  third  case  (No.  84)  is 
probably  a  case  who  will  get  well  with  a  year's 
change  and  rest. 

No  patient  should  be  discharged  from  the  Army 
till  cured.  It  is  cruel  to  send  these  men  back  into 
civil  life,  unless  they  have  a  good  post,  or  a  small 
pension.  The  hopeless  cases,  who  are  not  likely  to 
recover  whilst  in  the  Service,  may  perhaps  be  bribed 
into  improvement  by  an  understanding  that  as  soon 
as  they  are  better  they  will  be  discharged.  Suitable 
employment  should  be  found  for  them  before  they 
leave  the  Service. 

From  every  point  of  view  an  early  and  adequate 
treatment  of  these  cases  is  imperative  ;  many  of  the 
patients,  if  discharged  uncured,  will  sink  into  chronic 
invalidism.  The  artisan  who  feels  himself  unable  to 
continue  his  job,  even  though  he  have  a  small  pension, 
is,  with  the  necessary  limitation  of  his  interests,  a 
misery  to  himself  and  to  his  family. 


CHAPTER  VIII 
SUMMARY  OF  CONCLUSIONS 

(1)  WAR-SHOCK  is  hysteria  occurring  in  a  person 
free  from  hereditary  or  personal  psycho-neurotic 
antecedents,  but  with  a  mind  more  responsive  to 
psychical  stimulus  than  the  normal. 

(2)  The  wrenching  from  the  customary  calling  and 
life,    the   new   discipline,    the   peculiar  and  terrible 
mental  strain  of  modern  war-conditions  acting  upon 
this   sensitive   mind   determine   the   disease  among 
soldiers. 

(3)  In  100  consecutive   cases  of   psycho-neurosis 
70  per  cent,  correspond  to  this  description;  30  per 
cent,  have   neuropathic   antecedents,   hereditary  or 
personal ;  the  latter   correspond   more   closely  with 
the  psycho-neuroses  seen  in  civil  life. 

(4)  Shell-shock,  gas-poisoning,  or  other  physical 
injuries  do  not  cause  the  disease.     The   symptoms 
are  protean — palsies,  analgesia,  amblyopia,  mutism, 
deafness,  affections  of  the  vegetative  system  such  as 
the   soldier's   heart,  vomiting,    diarrhoea,  insomnia, 
loss  of  memory,  somnambulism,  phobias  and  obses- 
sions of  all  kinds. 

(5)  These    symptoms    are   the    result    of   mental 
conflicts  or  other  mental  phenomena  ;  all  the  symp- 
toms can  be  understood  in  terms  of  the  mind  without 
any  reference  to  physio-pathology. 

(6)  The  psycho-pathology  of  war-shock  is  that  of 

144 


SUMMARY  OF  CONCLUSIONS  145 

the  psycho-neuroses,  and  the  mechanisms  those  dis- 
covered by  Freud  in  hysteria. 

(7)  War-shock  is  not  a  new  disease  ;  it  is  a  variety 
of  hysteria  where  the  one  factor  (the  psychic  trauma) 
is  overwhelmingly  large  in  relation   to   the  second 
factor    (predisposition) ;  it   is   separated   from   non 
war-shock  cases  in  degree,  not  in  essence. 

(8)  The    treatment   par    excellence    is    hypnotic 
suggestion.     The    suggestion    by  preference   being 
directed  to   the   complex   as   determined   from   the 
psychological     examination    and     general    psycho- 
analytic conclusions. 

(9)  91 '5  per  cent,  of  cases  of  war-shock  were  cured 
by  this  method  and  8' 5   per  cent,  improved.       Of 
soldiers  with  previous  neuropathic  antecedents,  who 
form  only  a  third  of  the  total  number,  62  per  cent, 
were  cured  ;    27'6  per  cent,  improve  ;    and  10'4  per 
cent,  are  unaffected.     Cure  is  very  rapidly  effected  ; 
most  cases  are  well  in  less  than  two  weeks  ;  some  in 
a  few  minutes  or  hours. 

(10)  The  usual  objections  to  hypnotic  suggestion 
do  not  apply  to  war-shock  by  reason  of  the  absence 
of  neuropathic  antecedents. 

(11)  All  methods  of  treatment,  other  than  psycho- 
analysis, are  based  on  suggestion  ;  including  "  spon- 
taneous recovery,"  persuasion,  reasoning,symptomatic 
treatment,  electrotherapy,  etc.    The  objection  to  these 
indirect  forms  of   suggestion   is   that   they  are  less 
effective  (more  uncertain  and  less  rapid)  than  sugges- 
tion under  hypnosis. 

(12)  The  earlier  the  patients  are  treated  by  this 
method  the  better. 

(13)  The  majority  of  war-shock  patients  so  cured 
can  return  to  the  Front  in  three  to  six  months. 

(14)  Cases  of  "functional"  disease  should  not  be 
discharged  from  the  Army  until  cured. 


146 


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INDEX. 


ADRENIN,    increased   under 

emotion,  84 
After-treatment,  142 
Ambisexuality,  psychic,  98 
Amblyopia,   functional,  681) 

123 

Amblyopia,  persistent,  32 
Amnesia,  87 

Antecedents  of  patients.  8 
Anxiety-hysteria,  13,  78 
Anzacs    and    psychoneuro- 

sis,  17 

Aphonia,  30 
Astasia-abasia,  27 
Auto-mimicry,  48 

Babinski,  130, 133 
Bagehot,  on  dreams,  115 
Beard,  6 
Benon,  2 
Binswanger,  20 
Biological  functions,  112 
Blinking,  39,  57 
Boasting,  121 
Briand  et  Philippe,  138 

Campbell,  Dr.  Harry,  14 
Cannon,  W.  B.,  84 
Choking  of  libido,  93 
Claw-hand,  25 
Collecting  mania,  98 
Compensation,     psychologi- 
cal, 67 

Conflict,  17, 112 
Contracture  of  knee,  26 
Conversion-hysteria,  8,  48 

Deafness,  37, 126 
Degeneration  and  hvsteria. 

16 

Dejerine  et  Gauckler.  132 
Diagnostic    psycho-analysis, 

99 


Dreams,  92,  97, 103,  113-117 
Drop-wrist,  25 

Endopsychic  censure,  116 

Enuresis,  42 

Epilepsy,  word  associations, 

119 
Epileptic  fits  and  hysterical 

fits,  120 

Fear  and  desire,  102 
,,    repression  of,  79 

Forsyth,  D.,  13 

Frazer,  Sir  J.  G.,  65 

Freud,  7,  8,  44,  56,  58,  67  73 
95,  114 

Fugues,  88 

Functional  anaesthesia,  why 
left-sided,  61 

Functional      disease      and 
wounds,  4 

Ganser  twilight  state,  40 
Gatti,  Lodovici,  48 
Gaupp,  142 
Gesture,  symbolic,  63 
Grant  Dundas,  120 
Grasset,  4,  15 
Guthrie,  Leonard,  130 

Heart,  the  soldier's,  42 
Hemeralopia,  36 
Hemianalgesia,  psychology, 

of,  59 

Hemiplegia  and  mutism,  24 
Herz,  M.,  45 
Heteromimicry,  54 
Homosexuality,  110 
Horse,   identification    with 

54,  81 

Horse  symbolic,  82 
Horstmann,  3 
Hyperaeethesia,  21 


153 


154 


INDEX 


Hyperthyroidism,  blood  in, 

80 
Hysteria,  its  two  forms,  8 

Identification,  54 
Idio-Mnesis,  112 
Incest-motif,  11 

Janet,  Pierre,  8 
Jones,  Ernest,  78,  118 
Jung,  10,  90,  92,  94,  116, 119 

Laudenheimer,  13 
Lewandowsky,  62 
Leyton,  O.,  45 
Libido,  91,  93 

MacKenzie,  Sir  J.,  43 
Malingering,  125 
Masturbation,  64 
Memory,  loss  of,  73 

,,        practical,  89 
Mercier,  C.A.,  88,  89 
Milligan,  T.  C.,  137 
Money-complex,  98 
Mott,  F.  W.,  14,  28,  129 
Mutism,  psychology  of,  54 

69,  70 
Mutism,  shell-shock,  28 

„    without  shell-shock  29 
Myers,  C.  S.,  22 

Neurasthenia,  Beard's,  6 
,,  Freud's,  7 

Nonne,  3,  15,  133 

Obsessions,  108 
CEdipus-myth,  73 
Oppeuheimer,  1 .  3.  62 

Paraplegia,  71 
Predisposition,  2 
Prospective  tendency,  117 
Psychasthenia,  8,  95 
Psycho-analysis,  11, 132,  139 

,,   and  suggestion,  140,  141 
Psychoneuroses,  two  types, 

17 
Psychoses  excluded,  9 

, ,     German  statistics,  9 


Rationalization,  75 
Re-education,  138,  139 
Regression,  91 
Rest-cure,  evils  of,  141 
Rothmann,  3 

Self-deception,  106 

Sensory  symptoms,  20 

Sex,  rational,  102 

Shell-shock,  4 

Ships,  love  of,  111 

Smell,  disorders  of,  37 

Smith,  Elliot,  2,  14 

Soldiers'  interests,  103 
„        suggestible,  130 

Somnambulism,  86 

Speech-complex,  66 

Speech  disorders,  27 

Spirit,  life  of  the,  112 

Stammering,  30 

Stekel,  62 

Stewart,  Purves,  61,  123 

Stoney,  Florence,  85 

Sublimation,  91 

Suggestion  and  anaesthetic, 
136 

Suggestion,  collective,  135 
,        hypnotic,  134 
,        without  hypnosis, 
138 

Taste,  disorders  of,  38 
Tics,  39 

Transference,  56 
Treatment,  procedure,  134 
„          results,  128 

Unconscious,  archaic,  64 

,,  creative.  111 

Uncured,  143 

Vaso-motor  symptoms,  79 
Vomiting,  hysterical,  41 

War-shock,  2 
Wiltshire,  3 
Word-association,  90 
Words,   materialisation    of, 
64 


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